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Christiano AV, Goch AM, Burke CJ, Leucht P, Konda SR, Egol KA. Radiographic Humerus Union Measurement (RHUM) Demonstrates High Inter- and Intraobserver Reliability in Assessing Humeral Shaft Fracture Healing. HSS J 2020; 16:216-220. [PMID: 33380949 PMCID: PMC7749905 DOI: 10.1007/s11420-019-09680-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 02/27/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Orthopedic surgeons use radiographs to determine degrees of fracture healing, guide progression of clinical care, and assist in determining weight bearing and removal of immobilization. However, no gold standard exists to determine the progression of healing of humeral shaft fractures treated non-operatively. PURPOSE The purpose of this study was to determine whether a scale comparable to the modified Radiographic Union Score for Tibial (RUST) fractures applied to non-operatively treated humeral shaft fractures can increase interobserver reliability in determining fracture healing. METHODS A retrospective review was undertaken by three orthopedic traumatologists and one musculoskeletal radiologist, who evaluated 50 sets of anteroposterior and lateral radiographs, presented at random, of non-operatively treated humeral shaft fractures at various stages of healing from 17 patients. The radiographs were scored using a modified RUST scale called the Radiographic Humerus Union Measurement (RHUM). Observers were blinded to the time from injury. After a 4-week washout period, observers again scored the same radiographs. Observers classified each fracture as either healed or not healed based on the combination of radiographs. Inter- and intraobserver reliability of the RHUM were determined using an intraclass correlation coefficient (ICC). Interobserver reliability of determining a healed fracture was calculated using Cohen's kappa (κ) statistics. A receiver operator characteristic curve was conducted to determine the RHUM score predictive of a fracture being considered healed. RESULTS ICC demonstrated almost perfect interobserver reliability (ICC, 0.838; ICC 95% CI, 0.765 to 0.896) and intraobserver reliability (ICC range, 0.822 to 0.948) of the RHUM. κ demonstrated substantial agreement between observers in considering a fracture healed (κ = 0.647). Receiver operating characteristic (ROC) curve demonstrated that a RHUM of 10 or higher is an excellent predictor of the observer considering the fracture healed (area under the ROC curve = 0.946, specificity = 0.957, 95% CI specificity, 0.916 to 0.979). CONCLUSIONS This cortical scoring system has excellent interobserver reliability in humeral shaft fractures treated non-operatively. Consistent with previous cortical scoring systems, a RHUM score of 10 or above can be considered radiographically healed.
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Affiliation(s)
- Anthony V. Christiano
- grid.59734.3c0000 0001 0670 2351Department of Orthopaedic Surgery, Mount Sinai School of Medicine, 5 E. 98th Street, Box 1188, New York, NY 10029-6504 USA
| | - Abraham M. Goch
- grid.240283.f0000 0001 2152 0791Montefiore Medical Center, Bronx, NY USA
| | - Christopher J. Burke
- grid.137628.90000 0004 1936 8753NYU Langone Orthopedic Hospital, New York, NY USA
| | - Philipp Leucht
- grid.137628.90000 0004 1936 8753NYU Langone Orthopedic Hospital, New York, NY USA
| | - Sanjit R. Konda
- grid.137628.90000 0004 1936 8753NYU Langone Orthopedic Hospital, New York, NY USA ,grid.414915.c0000 0004 0414 4052Jamaica Hospital Medical Center, Queens, NY USA
| | - Kenneth A. Egol
- grid.137628.90000 0004 1936 8753NYU Langone Orthopedic Hospital, New York, NY USA
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Baron C, Nguyen VH, Naili S, Guivier-Curien C. Interaction of ultrasound waves with bone remodelling: a multiscale computational study. Biomech Model Mechanobiol 2020; 19:1755-1764. [DOI: 10.1007/s10237-020-01306-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 02/07/2020] [Indexed: 12/16/2022]
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Slobogean GP, Sprague S, Bzovsky S, Heels-Ansdell D, Thabane L, Scott T, Bhandari M. Fixation using alternative implants for the treatment of hip fractures (FAITH-2): design and rationale for a pilot multi-centre 2 × 2 factorial randomized controlled trial in young femoral neck fracture patients. Pilot Feasibility Stud 2019; 5:70. [PMID: 31161044 PMCID: PMC6540373 DOI: 10.1186/s40814-019-0458-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 05/13/2019] [Indexed: 12/02/2022] Open
Abstract
Background Femoral neck fractures in patients ≤ 60 years of age are often very different injuries compared to low-energy, hip fractures in elderly patients and are difficult to manage because of inherent problems associated with high-energy trauma mechanisms and increased functional demands for recovery. Internal fixation, with multiple cancellous screws or a sliding hip screw (SHS), is the most common treatment for this injury in young patients. However, there is no clinical consensus regarding which surgical technique is optimal. Additionally, there is compelling rationale to use vitamin D supplementation to nutritionally optimize bone healing in young patients. This pilot trial will determine feasibility and provide preliminary clinical data for a larger definitive trial. Methods We will conduct a multicenter, concealed randomized controlled pilot study, using a 2 × 2 factorial design in 60 patients aged 18–60 years with a femoral neck fracture. Eligible patients will be randomized in equal proportions to one of four groups: 1) SHS and vitamin D supplementation (4000 international units (IU) daily dose) for 6 months, 2) cancellous screws and vitamin D supplementation (4000 IU daily dose) for 6 months, 3) SHS and placebo, and 4) cancellous screws and placebo. Participants will be followed for 12 months post-fracture. Feasibility outcomes include initiation of clinical sites, recruitment, follow-up, data quality, and protocol adherence. Clinical outcomes, for both the pilot and planned definitive trials, include a composite of patient-important outcomes (re-operation, femoral head osteonecrosis, severe femoral neck malunion, and nonunion), health-related quality of life and patient-reported function, fracture healing complications, and radiographic fracture healing. A priori success criteria have been established. If the pilot study is deemed successful, study participants will be included in the definitive trial and clinical outcomes for the pilot will not be analyzed. If the pilot study is not deemed successful, clinical outcome data will be analyzed. Discussion Results of this study will inform the feasibility of a definitive trial. If clinical outcome data are analyzed, they will be disseminated through a publication and presentations. Trial registration The FAITH-2 trial, described as a definitive trial, was registered at ClinicalTrials.gov (NCT01908751) prior to enrollment of the first participant. Electronic supplementary material The online version of this article (10.1186/s40814-019-0458-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Gerard P Slobogean
- 1R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201 USA
| | - Sheila Sprague
- 2Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4L8 Canada.,3Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4L8 Canada
| | - Sofia Bzovsky
- 2Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4L8 Canada
| | - Diane Heels-Ansdell
- 3Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4L8 Canada
| | - Lehana Thabane
- 3Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4L8 Canada
| | - Taryn Scott
- 2Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4L8 Canada
| | - Mohit Bhandari
- 2Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4L8 Canada.,3Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4L8 Canada
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Christiano AV, Goch AM, Leucht P, Konda SR, Egol KA. Radiographic union score for tibia fractures predicts success with operative treatment of tibial nonunion. J Clin Orthop Trauma 2019; 10:650-654. [PMID: 31316233 PMCID: PMC6611993 DOI: 10.1016/j.jcot.2018.10.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 09/28/2018] [Accepted: 10/18/2018] [Indexed: 01/08/2023] Open
Abstract
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.
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Affiliation(s)
- Anthony V. Christiano
- Icahn School of Medicine at Mount Sinai, New York, NY, USA,Corresponding author. 1 Gustave L Levy Pl, Box 1188, New York, NY, 10029, USA.
| | | | | | - Sanjit R. Konda
- NYU Hospital for Joint Diseases, New York, NY, USA,Jamaica Hospital Medical Center, New York, NY, USA
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Inhibitory effects of low intensity pulsed ultrasound on osteoclastogenesis induced in vitro by breast cancer cells. JOURNAL OF EXPERIMENTAL & CLINICAL CANCER RESEARCH : CR 2018; 37:197. [PMID: 30126457 PMCID: PMC6102871 DOI: 10.1186/s13046-018-0868-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 08/07/2018] [Indexed: 12/17/2022]
Abstract
Background Bone tissue is one of the main sites for breast metastasis; patients diagnosed with advanced breast cancer mostly develop bone metastasis characterized by severe osteolytic lesions, which heavily influence their life quality. Low Intensity Pulsed Ultrasound (LIPUS) is a form of mechanical energy able to modulate various molecular pathways both in cancer and in health cells. The purpose of the present study was to evaluate for the first time, the ability of LIPUS to modulate osteolytic capability of breast cancer cells. Methods Two different approaches were employed: a) Indirect method -conditioned medium obtained by MDA-MB-231 cell line treated or untreated with LIPUS was used to induce osteoclast differentiation of murine macrophage Raw264.7 cell line; and b) Direct method -MDA-MB-231 were co-cultured with Raw264.7 cells and treated or untreated with LIPUS. Results LIPUS treatment impaired MDA-MB-231 cell dependentosteoclast differentiation and produced a reduction of osteoclast markers such as Cathepsin K, Matrix Metalloproteinase 9 and Tartrate Resistant Acid Phosphatase, suggesting its role as an effective and safe adjuvant in bone metastasis management. Conclusion LIPUS treatment could be a good and safety therapeutic adjuvant in osteolyitic bone metastasis not only for the induction properties of bone regeneration, but also for the reduction of osteolysis.
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Rutten S, van den Bekerom MPJ, Sierevelt IN, Nolte PA. Enhancement of Bone-Healing by Low-Intensity Pulsed Ultrasound: A Systematic Review. JBJS Rev 2018; 4:01874474-201603000-00006. [PMID: 27500435 DOI: 10.2106/jbjs.rvw.o.00027] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Low-intensity pulsed ultrasound (LIPUS) is frequently used to enhance or to accelerate fracture-healing, but its clinical role and effectiveness as a treatment modality remain uncertain. We performed a systematic review and meta-analysis of randomized controlled trials to determine the efficiency of LIPUS on bone-healing and/or fracture union, as well as on functional recovery. METHODS The databases of PubMed/MEDLINE, Cochrane Central Register of Controlled Trials, CINAHL, Web of Science, and Embase were searched for trials concerning LIPUS stimulation and bone-healing or fracture repair, in any language, published from the inception of the database to January 2, 2015. Eligible studies were randomized controlled trials that enrolled patients with any type of fracture, delayed union, or nonunion and randomly assigned them to LIPUS treatment or a control group. Two reviewers independently agreed on eligibility, assessed methodological quality, and extracted outcome data. All relevant outcomes were pooled, and a meta-analysis was performed. RESULTS Twenty-four unique randomized trials were selected for analysis after the search of all databases and the inclusion of one trial by the senior author. Time to radiographic fracture union was the most common primary outcome measure evaluated. After pooling the data concerning time to radiographic healing in the combined patient population (n = 429), LIPUS treatment resulted in a mean reduction in healing time of 39.8 days (95% confidence interval, 17.7 to 62.0 days; I = 94%). The most reduction in time to radiographic union by LIPUS treatment was seen in fractures with a long natural healing tendency. Three trials evaluating the time to return to work or active duty, as a surrogate for functional recovery, were unable to demonstrate a beneficial effect of LIPUS (n = 179). Evidence from two high-quality trials implied that LIPUS enhances fracture-healing through increased bone formation in cases of delayed and/or impaired bone-healing. The prevention of delayed union or nonunion by LIPUS treatment could not be demonstrated. CONCLUSIONS LIPUS treatment effectively reduces the time to radiographic fracture union, but this does not directly result in a beneficial effect of accelerated functional recovery or the prevention of delayed union or nonunion. The increase in bone formation as a result of LIPUS treatment may provide a valuable tool in fracture repair, but it does not always lead to healing. Future studies should focus on reporting of a combination of subjective signs of clinical healing, functional recovery, and radiographic union to determine the effectiveness of LIPUS treatment in clinical fracture-healing. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Sjoerd Rutten
- Department of Orthopaedic Surgery, Spaarne Hospital, Hoofddorp, the Netherlands
| | | | - Inger N Sierevelt
- Department of Orthopaedic Surgery, Spaarne Hospital, Hoofddorp, the Netherlands
| | - Petrus A Nolte
- Department of Orthopaedic Surgery, Spaarne Hospital, Hoofddorp, the Netherlands
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Tarride JE, Hopkins RB, Blackhouse G, Burke N, Bhandari M, Johal H, Guyatt GH, Busse JW. Low-intensity pulsed ultrasound for treatment of tibial fractures: an economic evaluation of the TRUST study. Bone Joint J 2017; 99-B:1526-1532. [PMID: 29092994 DOI: 10.1302/0301-620x.99b11.bjj-2017-0737] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 07/21/2017] [Indexed: 11/05/2022]
Abstract
AIMS This 501-patient, multi-centre, randomised controlled trial sought to establish the effect of low-intensity, pulsed, ultrasound (LIPUS) on tibial shaft fractures managed with intramedullary nailing. We conducted an economic evaluation as part of this trial. PATIENTS AND METHODS Data for patients' use of post-operative healthcare resources and time taken to return to work were collected and costed using publicly available sources. Health-related quality of life, assessed using the Health Utilities Index Mark-3 (HUI-3), was used to derive quality-adjusted life years (QALYs). Costs and QALYs were compared between LIPUS and control (a placebo device) from a payer and societal perspective using non-parametric bootstrapping. All costs are reported in 2015 Canadian dollars unless otherwise stated. RESULTS With a cost per device of $3,995, the mean cost was significantly higher for patients treated with LIPUS versus placebo from a payer (mean increase = $3647, 95% confidence interval (CI) $3244 to $4070; p < 0.001) or a societal perspective (mean increase = $3425, 95% CI $1568 to $5283; p < 0.001). LIPUS did not provide a significant benefit in terms of QALYs gained (mean difference = 0.023 QALYs, 95% CI -0.035 to 0.069; p = 0.474). Incremental cost-effectiveness ratios of LIPUS compared with placebo were $155 433/QALY from a payer perspective and $146 006/QALY from a societal perspective. CONCLUSION At the current price, LIPUS is not cost-effective for fresh tibial fractures managed with intramedullary nailing. Cite this article: Bone Joint J 2017;99-B:1526-32.
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Affiliation(s)
- J E Tarride
- McMaster University, and Member, Programs for Assessment of Technology in Health (PATH), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton, 43 Charlton Ave. East, 2nd Floor, Hamilton, Ontario, L8N 1Y3, Canada
| | - R B Hopkins
- McMaster University, and Member, Programs for Assessment of Technology in Health (PATH), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton, 43 Charlton Ave. East, 2nd Floor, Hamilton, Ontario, L8N 1Y3, Canada
| | - G Blackhouse
- McMaster University, and Member, Programs for Assessment of Technology in Health (PATH), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton, 43 Charlton Ave. East, 2nd Floor, Hamilton, Ontario, L8N 1Y3, Canada
| | - N Burke
- McMaster University, and Member, Programs for Assessment of Technology in Health (PATH), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton, 43 Charlton Ave. East, 2nd Floor, Hamilton, Ontario, L8N 1Y3, Canada
| | - M Bhandari
- McMaster University, 293 Wellington St. North, Suite 110, Hamilton, Ontario, L8L 8E7, Canada
| | - H Johal
- McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada
| | - G H Guyatt
- McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada
| | - J W Busse
- Department of Anesthesia, and Researcher, The Michael G. DeGroote Institute for Pain Research and Care, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada
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Abstract
BACKGROUND Low-intensity pulsed ultrasonography (LIPUS) is a form of mechanical stimulation that is delivered via a special device to the fracture site for the acceleration of fracture healing. We conducted a meta-analysis to assess the effect of LIPUS for fresh fractures in adults. METHODS MEDLINE, EMBASE and the Cochrane Library searched between Jan 1980 and Nov 2016. Studies should be quasi-randomized and randomized controlled trials (RCTs) comparing treatment with LIPUS to placebo or no treatment in adults with fresh fractures, reporting outcomes such as function; time to union; delayed union or non-union. Summary standard mean difference (SMD) and the risk ratio (RR) with their 95% confidence interval (CI) calculated with a random effects model. I statistic was used to assess the heterogeneity. Risk of bias was assessed by the Cochrane risk-of-bias tool. The GRADE system was used to evaluate the evidence quality. RESULTS A total of 12 trials with 1099 patients were included. The pooled results showed that LIPUS significantly reduced the time to fracture union (SMD: 0.65, 95% CI: 1.13 to 0.17), improved the quality of life (SMD: 0.20, 95% CI: 0.03-0.37) without affecting the time to full weight bearing (SMD: 0.76, 95% CI: 1.92 to 0.4), the time to return to work (SMD: 0.06, 95% CI: 0.14 to 0.27), or the incidence rate of delayed union and nonunion (RR: 1.02, 95% CI: 0.60-1.74). CONCLUSIONS Moderate-to-high quality evidence shows that LIPUS treatment reduces the time to fracture union and improves the quality of life without affecting functional recovery and incident rate of delayed union and nonunion, suggesting that LIPUS treatment may be a good treatment modality for adults with fresh fractures. However, there are some methodological limitations in the eligible trials, further studies are needed to determine the clinical circumstances under which LIPUS is truly valid and to examine the optimal approach for the use of this adjunctive therapy.
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Affiliation(s)
- Shenghan Lou
- Department of Orthopedics, Chinese PLA General Hospital, Beijing
- Department of Spine Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, P.R. China
| | - Houchen Lv
- Department of Orthopedics, Chinese PLA General Hospital, Beijing
| | - Zhirui Li
- Department of Orthopedics, Chinese PLA General Hospital, Beijing
| | - Licheng Zhang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing
| | - Peifu Tang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing
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Stengel D, Froese E, Mutschler W, Seifert J. Effektivität gepulsten Ultraschalls zur Beschleunigung der Knochenbruchheilung. Unfallchirurg 2017; 120:269-272. [DOI: 10.1007/s00113-017-0318-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Schandelmaier S, Kaushal A, Lytvyn L, Heels-Ansdell D, Siemieniuk RAC, Agoritsas T, Guyatt GH, Vandvik PO, Couban R, Mollon B, Busse JW. Low intensity pulsed ultrasound for bone healing: systematic review of randomized controlled trials. BMJ 2017; 356:j656. [PMID: 28348110 PMCID: PMC5484179 DOI: 10.1136/bmj.j656] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/01/2017] [Indexed: 11/16/2022]
Abstract
Objective To determine the efficacy of low intensity pulsed ultrasound (LIPUS) for healing of fracture or osteotomy.Design Systematic review and meta-analysis.Data sources Medline, Embase, CINAHL, Cochrane Central Register of Controlled Trials, and trial registries up to November 2016.Study selection Randomized controlled trials of LIPUS compared with sham device or no device in patients with any kind of fracture or osteotomy.Review methods Two independent reviewers identified studies, extracted data, and assessed risk of bias. A parallel guideline committee (BMJ Rapid Recommendation) provided input on the design and interpretation of the systematic review, including selection of outcomes important to patients. The GRADE system was used to assess the quality of evidence.Results 26 randomized controlled trials with a median sample size of 30 (range 8-501) were included. The most trustworthy evidence came from four trials at low risk of bias that included patients with tibia or clavicle fractures. Compared with control, LIPUS did not reduce time to return to work (percentage difference: 2.7% later with LIPUS, 95% confidence interval 7.7% earlier to 14.3% later; moderate certainty) or the number of subsequent operations (risk ratio 0.80, 95% confidence interval 0.55 to 1.16; moderate certainty). For pain, days to weight bearing, and radiographic healing, effects varied substantially among studies. For all three outcomes, trials at low risk of bias failed to show a benefit with LIPUS, while trials at high risk of bias suggested a benefit (interaction P<0.001). When only trials at low risk of bias trials were considered, LIPUS did not reduce days to weight bearing (4.8% later, 4.0% earlier to 14.4% later; high certainty), pain at four to six weeks (mean difference on 0-100 visual analogue scale: 0.93 lower, 2.51 lower to 0.64 higher; high certainty), and days to radiographic healing (1.7% earlier, 11.2% earlier to 8.8% later; moderate certainty).Conclusions Based on moderate to high quality evidence from studies in patients with fresh fracture, LIPUS does not improve outcomes important to patients and probably has no effect on radiographic bone healing. The applicability to other types of fracture or osteotomy is open to debate.Systematic review registration PROSPERO CRD42016050965.
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Affiliation(s)
- Stefan Schandelmaier
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada
- Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Spitalstrasse 12, CH-4031 Basel, Switzerland
| | - Alka Kaushal
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON L8S 4K1, Canada
| | - Lyubov Lytvyn
- Oslo University Hospital, Forskningsveien 2b, Postboks 1089, Blindern 0317 Oslo, Norway
| | - Diane Heels-Ansdell
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada
| | - Reed A C Siemieniuk
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, University of Toronto, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Thomas Agoritsas
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada
- Division General Internal Medicine and Division of Clinical Epidemiology, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1211, Geneva, Switzerland
| | - Gordon H Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada
- Department of Medicine, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada
| | - Per O Vandvik
- Institute of Health and Society, Faculty of Medicine, University of Oslo, 0318 Oslo, Norway
- Department of Medicine, Innlandet Hospital Trust-division, Gjøvik, Norway
| | - Rachel Couban
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON L8S 4K1, Canada
| | - Brent Mollon
- Orillia Soldiers' Memorial Hospital, 41 Frederick Street, Orillia, ON L3V 5W6, Canada
| | - Jason W Busse
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, ON L8S 4L8, Canada
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON L8S 4K1, Canada
- Department of Anesthesia, McMaster University, Hamilton, ON L8S 4K1, Canada
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Busse JW, Bhandari M, Einhorn TA, Schemitsch E, Heckman JD, Tornetta P, Leung KS, Heels-Ansdell D, Makosso-Kallyth S, Della Rocca GJ, Jones CB, Guyatt GH. Re-evaluation of low intensity pulsed ultrasound in treatment of tibial fractures (TRUST): randomized clinical trial. BMJ 2016; 355:i5351. [PMID: 27797787 PMCID: PMC5080447 DOI: 10.1136/bmj.i5351] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To determine whether low intensity pulsed ultrasound (LIPUS), compared with sham treatment, accelerates functional recovery and radiographic healing in patients with operatively managed tibial fractures. DESIGN A concealed, randomized, blinded, sham controlled clinical trial with a parallel group design of 501 patients, enrolled between October 2008 and September 2012, and followed for one year. SETTING 43 North American academic trauma centers. PARTICIPANTS Skeletally mature men or women with an open or closed tibial fracture amenable to intramedullary nail fixation. Exclusions comprised pilon fractures, tibial shaft fractures that extended into the joint and required reduction, pathological fractures, bilateral tibial fractures, segmental fractures, spiral fractures >7.5 cm in length, concomitant injuries that were likely to impair function for at least as long as the patient's tibial fracture, and tibial fractures that showed <25% cortical contact and >1 cm gap after surgical fixation. 3105 consecutive patients who underwent intramedullary nailing for tibial fracture were assessed, 599 were eligible and 501 provided informed consent and were enrolled. INTERVENTIONS Patients were allocated centrally to self administer daily LIPUS (n=250) or use a sham device (n=251) until their tibial fracture showed radiographic healing or until one year after intramedullary fixation. MAIN OUTCOME MEASURES Primary registry specified outcome was time to radiographic healing within one year of fixation; secondary outcome was rate of non-union. Additional protocol specified outcomes included short form-36 (SF-36) physical component summary (PCS) scores, return to work, return to household activities, return to ≥80% of function before injury, return to leisure activities, time to full weight bearing, scores on the health utilities index (mark 3), and adverse events related to the device. RESULTS SF-36 PCS data were acquired from 481/501 (96%) patients, for whom we had 2303/2886 (80%) observations, and radiographic healing data were acquired from 482/501 (96%) patients, of whom 82 were censored. Results showed no impact on SF-36 PCS scores between LIPUS and control groups (mean difference 0.55, 95% confidence interval -0.75 to 1.84; P=0.41) or for the interaction between time and treatment (P=0.30); minimal important difference is 3-5 points) or in other functional measures. There was also no difference in time to radiographic healing (hazard ratio 1.07, 95% confidence interval 0.86 to 1.34; P=0.55). There were no differences in safety outcomes between treatment groups. Patient compliance was moderate; 73% of patients administered ≥50% of all recommended treatments. CONCLUSIONS Postoperative use of LIPUS after tibial fracture fixation does not accelerate radiographic healing and fails to improve functional recovery.Study registration ClinicalTrialGov Identifier: NCT00667849.
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Affiliation(s)
- Jason W Busse
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, L8S 4K1, Canada
- Department of Anesthesia, McMaster University, Hamilton, ON L8S 4K1, Canada
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON L8S 4K1, Canada
| | - Mohit Bhandari
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, L8S 4K1, Canada
- Department of Surgery, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Thomas A Einhorn
- Department of Orthopedic Surgery, NYU Langone Medical Center, New York, NY 10016, USA
| | - Emil Schemitsch
- Department of Surgery, University of Western Ontario, London, ON N6A 4V2, Canada
| | - James D Heckman
- Department of Orthopedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03766, USA
| | - Paul Tornetta
- Department of Orthopedic Surgery, NYU Langone Medical Center, New York, NY 10016, USA
| | - Kwok-Sui Leung
- Department of Orthopedics and Traumatology, Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Diane Heels-Ansdell
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, L8S 4K1, Canada
| | | | | | - Clifford B Jones
- Center for Orthopedic Research and Education, CORE, Banner University, Phoenix, AZ, 85023, USA
| | - Gordon H Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, L8S 4K1, Canada
- Department of Medicine, McMaster University, Hamilton, ON L8S 4K1, Canada
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Briel M, Olu KK, von Elm E, Kasenda B, Alturki R, Agarwal A, Bhatnagar N, Schandelmaier S. A systematic review of discontinued trials suggested that most reasons for recruitment failure were preventable. J Clin Epidemiol 2016; 80:8-15. [PMID: 27498376 DOI: 10.1016/j.jclinepi.2016.07.016] [Citation(s) in RCA: 116] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 07/14/2016] [Accepted: 07/29/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To collect and classify reported reasons for recruitment failure in discontinued randomized controlled trials (RCTs) and to assess reporting quality. METHODS We systematically searched MEDLINE and EMBASE (2010-2014) and a previous cohort of RCTs for published RCTs reporting trial discontinuation due to poor recruitment. Teams of two investigators selected eligible RCTs working independently and extracted information using standardized forms. We used an iterative approach to classify reasons for poor recruitment. RESULTS We included 172 RCTs discontinued due to poor recruitment (including 26 conference abstracts and 63 industry-funded RCTs). Of those, 131 (76%) reported one or more reasons for discontinuation due to poor recruitment. We identified 28 different reasons for recruitment failure; most frequently mentioned were overestimation of prevalence of eligible participants and prejudiced views of recruiters and participants on trial interventions. Few RCTs reported relevant details about the recruitment process such as how eligible participants were identified, the number of patients assessed for eligibility, and who actually recruited participants. CONCLUSION Our classification could serve as a checklist to assist investigators in the planning of RCTs. Most reasons for recruitment failure seem preventable with a pilot study that applies the planned informed consent procedure.
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Affiliation(s)
- Matthias Briel
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Spitalstrasse 12, 4031 Basel, Switzerland; Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4K1, Canada.
| | - Kelechi Kalu Olu
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Spitalstrasse 12, 4031 Basel, Switzerland
| | - Erik von Elm
- Cochrane Switzerland, Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital, Route de la Corniche 10, Lausanne, 1010, Switzerland
| | - Benjamin Kasenda
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Spitalstrasse 12, 4031 Basel, Switzerland; Department of Oncology, University Hospital Basel, Petersgraben 4, Basel, 4031, Switzerland
| | - Reem Alturki
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Spitalstrasse 12, 4031 Basel, Switzerland
| | - Arnav Agarwal
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4K1, Canada
| | - Neera Bhatnagar
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4K1, Canada
| | - Stefan Schandelmaier
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Spitalstrasse 12, 4031 Basel, Switzerland; Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4K1, Canada
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Cochrane in CORR (®): Ultrasound and Shockwave Therapy for Acute Fractures in Adults (Review). Clin Orthop Relat Res 2016; 474:1553-9. [PMID: 27048220 PMCID: PMC4887373 DOI: 10.1007/s11999-016-4816-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 03/29/2016] [Indexed: 01/31/2023]
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Low-intensity continuous ultrasound triggers effective bisphosphonate anticancer activity in breast cancer. Sci Rep 2015; 5:16354. [PMID: 26578234 PMCID: PMC4649676 DOI: 10.1038/srep16354] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 09/14/2015] [Indexed: 01/30/2023] Open
Abstract
Ultrasound (US) is a non-ionizing pressure wave that can produce mechanical and thermal effects. Bisphosphonates have demonstrated clinical utility in bone metastases treatment. Preclinical studies suggest that bisphosphonates have anticancer activity. However, bisphosphonates exhibit a high affinity for bone mineral, which reduces their bioavailibity for tumor cells. Ultrasound has been shown to be effective for drug delivery but in interaction with gas bubbles or encapsulated drugs. We examined the effects of a clinically relevant dose of bisphosphonate zoledronate (ZOL) in combination with US. In a bone metastasis model, mice treated with ZOL+US had osteolytic lesions that were 58% smaller than those of ZOL-treated animals as well as a reduced skeletal tumor burden. In a model of primary tumors, ZOL+US treatment reduced by 42% the tumor volume, compared with ZOL-treated animals. Using a fluorescent bisphosphonate, we demonstrated that US forced the release of bisphosphonate from the bone surface, enabling a continuous impregnation of the bone marrow. Additionally, US forced the penetration of ZOL within tumors, as demonstrated by the intratumoral accumulation of unprenylated Rap1A, a surrogate marker of ZOL antitumor activity. Our findings made US a promising modality to trigger bisphosphonate anticancer activity in bone metastases and in primary tumors.
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Drissi H, Paglia DN, Alaee F, Yoshida R. Constructing the toolbox: Patient-specific genetic factors of altered fracture healing. Genes Dis 2014; 1:140-148. [PMID: 25558470 PMCID: PMC4280851 DOI: 10.1016/j.gendis.2014.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 07/18/2014] [Indexed: 01/10/2023] Open
Abstract
The multifaceted sequence of events that follow fracture repair can be further complicated when considering risk factors for impaired union, present in a large and growing percentage of the population. Risk factors such as diabetes, substance abuse, and poor nutrition affect both the young and old alike, and have been shown to dramatically impair the body's natural healing processes. To this end, biotherapeudic interventions such as ultrasound, electrical simulation, growth factor treatment (BMP-2, BMP-7, PDGF-BB, FGF-2) have been evaluated in preclinical models and in some cases are used widely for patients with established non-union or risk/indication or impaired healing (ie. ultrasound, BMP-2, etc.). Despite the promise of these interventions, they have been shown to be reliant on patient compliance and can produce adverse side-effects such as heterotopic ossification. Gene and cell therapy approaches have attempted to apply controlled regimens of these factors and have produced promising results. However, there are safety and efficacy concerns that may limit the translation of these approaches. In addition, none of the above mentioned approaches consider genetic variation between individual patients. Several clinical and preclinical studies have demonstrated a genetic component to fracture repair and that SNPs and genetic background variation play major roles in the determination of healing outcomes. Despite this, there is a need for preclinical data to dissect the mechanism underlying the influence of specific gene loci on the processes of fracture healing, which will be paramount in the future of patient-centered interventions for fracture repair.
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Affiliation(s)
- Hicham Drissi
- New England Musculoskeletal Institute and Department of Orthopaedic Surgery, United States
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Griffin XL, Parsons N, Costa ML, Metcalfe D. Ultrasound and shockwave therapy for acute fractures in adults. Cochrane Database Syst Rev 2014; 2014:CD008579. [PMID: 24956457 PMCID: PMC7173732 DOI: 10.1002/14651858.cd008579.pub3] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The morbidity and socioeconomic costs of fractures are considerable. The length of time to healing is an important factor in determining a person's recovery after a fracture. Ultrasound may have a therapeutic role in reducing the time to union after fracture. This is an update of a review previously published in February 2012. OBJECTIVES To assess the effects of low-intensity ultrasound (LIPUS), high-intensity focused ultrasound (HIFUS) and extracorporeal shockwave therapies (ECSW) as part of the treatment of acute fractures in adults. SEARCH METHODS We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (2 June 2014), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2014, Issue 5), MEDLINE (1946 to May Week 3 2014), EMBASE (1980 to 2014 Week 22), trial registers and reference lists of articles. SELECTION CRITERIA Randomised and quasi-randomised controlled trials evaluating ultrasound treatment in the management of acute fractures in adults. Studies had to include participants over 18 years of age with acute fractures, reporting outcomes such as function; time to union; non-union; secondary procedures such as for fixation or delayed union or non-union; adverse effects; pain; costs; and patient adherence. DATA COLLECTION AND ANALYSIS Two authors independently extracted data from the included studies. Treatment effects were assessed using mean differences, standardised mean differences or risk ratios using a fixed-effect model, except where there was substantial heterogeneity, when data were pooled using a random-effects model. Results from 'worst case' analyses, which gave more conservative estimates of treatment effects for time to fracture union, are reported in preference to those from 'as reported' analyses. MAIN RESULTS We included 12 studies, involving 622 participants with 648 fractures. Eight studies were randomised placebo-controlled trials, two were randomised controlled trials without placebo controls, one was a quasi-randomised placebo-controlled trial and one was a quasi-randomised controlled trial without placebo control. Eleven trials tested LIPUS and one trial tested ECSW. Four trials included participants with conservatively treated upper limb complete fractures and six trials included participants with lower limb complete fractures; these were surgically fixed in four trials. The remaining two trials reported results for conservatively treated tibial stress fractures.'Risk of bias' assessment of the included studies was hampered by the poor reporting of methods, frequently resulting in the risk of bias of individual domains being judged as 'unclear'. Both quasi-randomised studies were at high risk of bias, including selection and attrition bias. Three studies were at low risk of selection bias relating to allocation concealment the majority of studies were at low risk of performance bias as they employed a form of intervention blinding.Only limited data were available from three of only four studies reporting on functional outcome. One study of complete fractures found little evidence of a difference between the two groups in the time to return to work (mean difference (MD) 1.95 days favouring control, 95% confidence interval (CI) -2.18 to 6.08; 101 participants). Pooled data from two studies found LIPUS did not significantly affect the time to return to training or duty in soldiers or midshipmen with stress fractures (MD -8.55 days, 95% CI -22.71 to 5.61; 93 participants).We adopted a conservative strategy for data analysis that was more likely to underestimate than to overestimate a benefit of the intervention. After pooling results from eight studies (446 fractures), the data showed no statistically significant reduction in time to union of complete fractures treated with LIPUS (standardised mean difference (SMD) -0.47, 95% CI -1.14 to 0.20). This result could include a clinically important benefit or harm, and should be seen in the context of the highly significant statistical heterogeneity (I² = 90%). This heterogeneity was not explained by the a priori subgroup analyses (upper limb versus lower limb fracture, smoking status). An additional subgroup analysis comparing conservatively and operatively treated fractures raised the possibility that LIPUS may be effective in reducing healing time in conservatively managed fractures, but the test for subgroup differences did not confirm a significant difference between the subgroups.Pooled results from five of the eight trials (333 fractures) reporting proportion of delayed union or non-union showed no significant difference between LIPUS and control (10/168 versus 13/165; RR 0.75; 95% CI 0.24 to 2.28). Adverse effects directly associated with LIPUS and associated devices were found to be few and minor, and compliance with treatment was generally good. One study reporting on pain scores found no difference between groups at eight weeks (101 participants).One quasi-randomised study found no significant difference in non-union at 12 months between internal fixation supplemented with ECSW and internal fixation alone (3/27 versus 6/30; RR 0.56, 95% CI 0.15 to 2.01). There was a clinically small but statistically significant difference in the visual analogue scores for pain in favour of ECSW at three month follow-up (MD -0.80, 95% CI -1.23 to -0.37). The only reported complication was infection, with no significant difference between the two groups. AUTHORS' CONCLUSIONS While a potential benefit of ultrasound for the treatment of acute fractures in adults cannot be ruled out, the currently available evidence from a set of clinically heterogeneous trials is insufficient to support the routine use of this intervention in clinical practice. Future trials should record functional outcomes and follow-up all trial participants.
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Affiliation(s)
- Xavier L Griffin
- University of WarwickWarwick Orthopaedics, Warwick Medical SchoolClinical Sciences BuildingClifford Bridge RoadCoventryUKCV2 2DX
| | - Nick Parsons
- University of WarwickWarwick Orthopaedics, Warwick Medical SchoolClinical Sciences BuildingClifford Bridge RoadCoventryUKCV2 2DX
| | - Matthew L Costa
- University of WarwickWarwick Clinical Trials UnitCoventryWarwickshireUKCV4 7AL
| | - David Metcalfe
- University of WarwickWarwick Orthopaedics, Warwick Medical SchoolClinical Sciences BuildingClifford Bridge RoadCoventryUKCV2 2DX
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