Assessment Of Fracture Healing Research Articles

Clinical effect of day case arthroscopic surgery in tibial-eminence fracture in adults using button plates

BackgroundThe tibial-eminence fracture (TEF) is an anterior cruciate-ligament avulsion fracture with a low incidence. Many surgical techniques have been described, but none of them allow early functional exercise, and there are many postoperative complications.PurposesThis study aimed to evaluate the early clinical efficacy and complications of day case arthroscopic-surgery treatment of adult TEF with button plates.MethodsWe retrospectively analyzed patients with TEF treated with arthroscopic surgery. Clinical subjective evaluation included International Knee Documentation Committee (IKDC) subjective score, Lysholm Knee Score, and Visual Analog Scale (VAS) score. Knee joint scores were evaluated by Lysholm score. Clinical objective assessment included the Lachman test, anterior-drawer test (ADT), IKDC, and range of motion. We assessed patient quality of life using a life summary table. Assessment of fracture healing and internal fixation was based on lateral x-rays of the knee joint. We measured and evaluated patient satisfaction at the last follow-up in accordance with Marsh criteria.ResultsAt final follow-up (average follow-up time, 28.23 ± 3.14 months), we evaluated results from 22 patients (22 knees). Average patient age during surgery was 33.64 ± 6.96 years. Average time from injury to surgery was 6.59 ± 1.47 h. Postoperative function was better than pre-operative function in all patients. IKDC subjective score, Lysholm score, and VAS score were better at final follow-up than before surgery. Differences in Lachman test and ADT scores before and after surgery were statistically significant. According to Intra-articular button position classification, 6 patients (6 knees) showed ideal position (A), 16 patients (16 knees) showed nearly ideal position (B), and none of the patients had nonideal position (C). The fractures of 22 patients healed completely; 2 patients had a 5°–10° knee joint dysfunction, and 1 had an abnormal knee sound. According to intra-articular button position classification, the rate of ideal position was 100%. Patient satisfaction rate was 81.8%.ConclusionDay surgery using double-button plates to treat TEF could achieve anatomical reduction, power and stability, as well as good clinical efficacy.

Application of tomosynthesis for vertebral compression fracture diagnosis and bone healing assessment in fracture liaison services.

Early identification of vertebral compression fractures (VCFs) is crucial for successful secondary fracture prevention. Tomosynthesis, a low-dose tomographic imaging technique, may facilitate the evaluation and long-term follow-up of VCFs in patients with osteoporosis. Herein, we compared the performances of plain radiography and tomosynthesis for VCF diagnosis and healing assessment in patients enrolled in fracture liaison services in our hospital. Forty-nine patients with new VCFs at the T10–L5 levels were prospectively recruited between August 2018 and May 2020; all patients underwent thoracolumbar plain radiography and tomosynthesis. We evaluated the accuracy of the VCF diagnosis, image quality, and VCFs healing process. Tomosynthesis identified 90 levels of VCF in 49 patients, while plain radiography revealed only 87.8% (79/90) of them. There were 44.9% (22/49) patients with neglected chronic VCFs as seen on tomosynthesis. Tomosynthesis images had improved VCF diagnostic accuracy up to 12.2% and showed significantly more anatomic details than plain radiography. For diagnosis of VCFs, the performance of plain radiographs was poorer than that of tomosynthesis images (plain radiographs: sensitivity 84%, specificity 93.5%, false positive rate 6.5%, and false negative rate 16%; tomosynthesis: sensitivity 93.2%, specificity 100%, false positive rate 0%, and false negative 6.8%), using magnetic resonance imaging (MRI) as gold standard. The Kappa coefficient between Tomosynthesis and MRI is 0.956 while between radiography and MRI is 0.704. Tomosynthesis showed significantly more anatomic details than plain radiography and all the examiners revealed a clear preference for tomosynthesis. Tomosynthesis scored 3.3 times higher on the fracture healing assessment at the 3-month follow-up than plain radiographs. Tomosynthesis is a promising tool for VCF screening and diagnosis in patients with osteoporosis and for monitoring fracture healing status at a low radiation dose and cost.

Radiographic Evaluation of Distal Radius Fracture Healing by Time: Orthopedist versus Qualitative Assessment of Image Processing

Distal radius fractures are among the most prevalent long-bone fractures in the body. Fracture healing assessment is based on clinical evaluation and radiological examinations. A lack of consensus exists regarding the radiographic criteria for fracture union. Our work examined the commonly used criteria for the assessment of fracture healing. Thirty-two patients, conservatively treated for distal radius fracture, participated in a prospective study. Enrolled patients followed protocol for 26 weeks. Four orthopedic surgeons with similar ranks were asked to evaluate three parameters of radiographic measurements for each set of radiographs, including callus formation, the presence of a fracture line, and bridging of fracture sites or sites of fracture edges in 70 radiographs. Ten patients were eligible for the study. The degree of agreement among surgeons was “good” (Cronbach’s alpha): callus formation—0.8, bridging of fracture sites—0.775, blurring of fracture line gap—0.795. A timeline based on the specific week and grading system was made. Radiographic detection of callus formation was seen after the second film, between 6 and 9 weeks, and an agreement among surgeons was achieved for more than half of the patients for the blurring of the fracture gap. The radiographic healing progression of the distal radius can be detected after 6 and 9 weeks in all three parameters with good agreement between different surgeons. A timeline graph such as the one that was made in this model can be used for the follow-up of patients’ fracture healing or early detection of non-union.

Treatment of inferior pole patella fracture using Krackow suturing combined with the suture bridge technique.

To evaluate the feasibility and clinical effect of Krackow suturing combined with the suture bridge technique for the treatment of acute inferior pole patella fracture. In this study, 18 patients with acute inferior pole patella fracture who received treatment using Krackow suturing combined with the suture bridge technique between January 2019 and March 2020 were retrospectively reviewed. There were 10 men and 8 women, with an average age of 50.1years (range 24-69years). X-ray examinations were performed to assess fracture healing and the Insall-Salvati index. The clinical effect was measured by the range of motion of the knee joint and the Böstman scale. Patients were followed up for 13-26months, with an average follow-up period of 19.6months. X-ray indicated that fracture union had occurred in all patients by 10.1weeks after surgery on average (range 8-14weeks). The mean Insall-Salvati index immediately after surgery and at the final follow-up was 0.98 ± 0.07 and 0.90 ± 0.22, respectively (P > 0.05). At the last follow-up, the mean flexion and extension ranges for the knee joint were 135.8° ± 8.8° and -2.8° ± 3.9°, respectively, and the mean Böstman scale was 28.9 ± 1.1 points. Functional recovery was excellent in 17 patients and good in one patient, resulting in an overall good/excellent recovery rate of 100%. Our results indicated that Krackow suturing combined with the suture bridge technique can achieve stable fracture fixation, provides good clinical outcomes in the treatment of acute inferior pole patella fracture, and is worthy of clinical application.

Outcomes of the Carlson Approach in the Treatment of Posterior Tibial Plateau Fractures.

Objectives To describe a series of cases of tibial fractures surgically treated using the posterior approach as described by Carlson, focusing on evaluating its functional results and complication rate. Methods Eleven patients with tibial plateau fractures, who underwent surgical treatment using the Carlson approach from July to December 2019, were followed-up. The minimum follow-up period was defined as 6 months. The American Knee Society Score (AKSS), American Knee Society Score/Function (AKSS/Function) and the Lysholm score were used to check treatment results at 6 months after the fracture. The patients underwent standard anteroposterior and lateral radiographs to assess fracture healing, and clinical healing was determined by the absence of pain during full weight-bearing. Results The mean follow-up period was 12 months (9-16 months). The primary mechanism of trauma was motorcycle accident, and the most prevalent side of fracture was the right side. Eight participants were male. The mean age of the patients was 28 years. All fractures healed, and none of the patients presented complications. The AKSS was excellent in 11 patients, with a mean AKSS/Function of 99.1 ± 3, and Lysholm scores with a median of 95.0 ± 5.6. Conclusions The Carlson approach for posterior fractures of the tibial plateau can be considered safe, presenting a low complication rate and satisfactory functional results.

Postmortem and Antemortem Forensic Assessment of Pediatric Fracture Healing from Radiographs and Machine Learning Classification.

Simple SummaryBeing able to estimate from X-rays alone how long ago a child’s bone was fractured is important for prosecuting suspected child abuse of living or dead children. This estimate can also help identify a child when all that remains are bones. Experts use various indicators to make these estimates of the age of healing and fully healed fractures, in living and deceased persons, even years after the injury occurred. However, it is not a precise science. We proposed a method using a new combination of indicators to classify fracture healing in children and adolescents. We tested its accuracy with a public database of X-rays of children’s fractures taken during the treatment and healing process. We used part of the X-ray database for training artificial intelligence (AI, or machine learning) programs to classify stages of bone healing when using our new system. We used another portion of the same database to test the performance of the AI system that had been trained with our new classification system. Our new system addresses certain classification ambiguities of a currently used system and is similar in accuracy.A timeline of pediatric bone healing using fracture healing characteristics that can be assessed solely using radiographs would be practical for forensic casework, where the fracture event may precede death by days, months, or years. However, the dating of fractures from radiographs is difficult, imprecise, and lacks consensus, as only a few aspects of the healing process are visible on radiographs. Multiple studies in both the clinical and forensic literature have attempted to develop a usable scale to assess pediatric bone healing on radiographs using various healing characteristics. In contrast to the orthopedic definition, a fracture in forensic casework is only considered to be healed when the area around the fracture has been remodeled to the point that the fracture is difficult to detect on a radiograph or on the surface of the bone itself, a process that can take several years. We subjectively assessed visible characteristics of healing in radiograms of fractures occurring in 942 living children and adolescents. By dividing these assessments into learning and test (validation) sets, the accuracy of a newly proposed fracture healing scale was compared to a previous study. Two machine learning models were used to test predictions of the new scale. All three models produced similar estimates with substantial imprecision. Results corroborate the Malone model with an independent dataset and support the efficacy of using less complex models to estimate fracture age in children.

3D reduction combined with the modified Kirschner-wire tension band for the treatment of comminuted patella fracture.

A novel 3D reduction method combined with a modified Kirschner-wire tension band (3D MKTB) fixation method to treat comminuted patella fractures was introduced in this study. This study aims to evaluate the effectiveness and practicality of this novel technology. This study is a retrospective case series study. Twenty-eight patients with closed comminuted patella fractures were treated with the novel 3D MKTB fixation method. Radiographs of the knee were obtained at the routine follow-up to assess fracture healing and widening of the articular step-off. Clinical outcomes including the degree of pain on a visual analogue scale (VAS), range of motion, Lysholm, and Bostman grading scales were measured at the last follow-up. The mean follow-up was 39.8 ± 10.5 (range 26-62) months. All patients had bony union at a mean of 11.4 ± 1.4 (range 9-14weeks) weeks based on X-ray. No patient had evidence of internal fixation failure. Only two patients suffered from surgical complication. One patient suffered from postoperative superficial infection, and one patient suffered from internal fixation irritation. Articular step-off larger than 2mm was not seen in any cases. The average VAS-related pain score was 0.5 ± 0.5 (range 0-1) points. The average range of motion was 0-138.6° ± 11.9° (range 90°-155°), all patients had full knee extension. The mean Lysholm and Bostman scores were 92.9 ± 3.5 (range 86-100 points) points and 28.5 ± 1.3 (range 24-30 points) points, respectively. The novel 3D reduction technique combined with the modified Kirschner-wire tension band technique is an effective, safe, and simple treatment option for comminuted patella fractures. IV.

Future modalities to assess fracture healing.

Objectives:Fracture healing remains a complex process routinely evaluated in clinical practice with sequential radiographs. Assessing the presence of union is a critical issue in patient care, with widespread implications in terms of overall decision-making and postoperative rehabilitation. Nonunion assessment, whether it be with radiographs or more advanced imaging, has far-reaching consequences for the patient in addition to the health care system. The purpose of this review was to explore new, emerging modalities for the assessment of fracture healing.Methods:A review of the current, relevant literature regarding the use of serologic markers and radiostereometric analysis was conducted, and the results were summarized.Results:Emerging techniques to assess fracture healing have been evaluated, including the use of serologic markers as well as radiostereometric analysis. Their potential applications extend beyond the simple assessment of a united fracture, with the capacity to predict nonunion at earlier phases of care.Conclusions:While early results appear promising, the current application of serologic markers and radiostereometric analysis as a means to assess fracture healing remains limited, and future larger-scale studies are needed to establish concrete and tailored guidelines for use.

Prospective Comparative Study of Fixing Displaced Transverse Patellar Fracture by Tension Band Wiring Versus Cannulated Screws with Wiring

BACKGROUND: Transverse fractures of the patella are important fractures with a wide variety of subtypes, the common incidence in the age group of 20–50 years. Surgical interference aims to achieve a perfect alignment of the joint surface, in addition to rigid fixation of the fracture for early re-habitation and early movement to retain the extensor mechanism of the knee joint. AIM: The aim of this study was to compare the radiological and functional outcomes of the displaced transverse patella fracture in adult patients treated by ORIF using tension band wiring versus cannulated screws with wiring. METHODS: A prospective analytic comparative study was conducted in Al-Kindy Teaching Hospital/Baghdad/Iraq for 18 months from April 1, 2019, to October 1, 2020. It included 32 patients with isolated displaced transverse patellar fracture AO type 34-C1. The patients have undergone operative fixation with two different surgical techniques divided randomly by choosing every other patient into two groups. Group A, the fracture was fixed by cannulated screws with wiring and Group B, the fracture was fixed by two K-wires and with tension band technique. Postoperatively, assessment of the knee function by Lysholm score, the visual analog scale for pain intensity, and active flexion range of movement were measured in degree as primary outcomes, while time to union in weeks assessed radiographically as secondary outcomes. RESULTS: The patients’ age was ranging from 26 to 49 years, with males predominant. Low-energy falls occupying a major part of the mechanism of injury in both groups. Lysholm score was significantly increased after 3, 6, and 12 months compared to that after 1 month in both groups with no statistical differences. The mean visual analog score significantly decreased in Group A after 1 month than that in Group B with no significant change in the other follow-up periods. There were no statistically significant differences in both groups regarding the range of knee movement and the radiographic assessment of fracture healing. CONCLUSION: Both techniques are good and effective with taking into consideration that open reduction and cannulated screws fixation with wiring technique is shown to be associated with lower post-operative pain and a lower frequency of complications mainly surgical site infection.

Effectiveness analysis of medial buttress plate augmented hollow lag screws fixation in combination with sartorius pedicled iliac flap for the treatment of femoral neck fractures in young adults

To evaluate the effectiveness of medial buttress plate augmented hollow lag screws fixation in combination with sartorius pedicled iliac flap for the treatment of femoral neck fractures in young adults. The clinical data of 11 young adult patients with femoral neck fractures between February 2013 and February 2019 were analyzed retrospectively. There were 7 males and 4 females with a mean age of 45 years (range, 32-58 years). Fractures were caused by falling from height in 6 cases, by traffic accident in 4 cases, and by sports injury in 1 case. There were 7 cases in the left hip and 4 cases in the right hip. The mean Pauwels angle was 64° (range, 55°-75°). All patients were treated by medial buttress plate augmented hollow lag screws fixation and sartorius pedicled iliac flap. The X-ray film of pelvis, lateral X-ray film of hip joint, CT scan and three-dimensional reconstruction of hip joint were taken after operation to assess fracture healing and position of the internal fixators. The postoperative hip function was evaluated according to the Harris score. All the incisions healed by first intention, and no complication such as incision infection and lateral femoral cutaneous nerve injury happened. Re-examination on the second day after operation showed that reduction and fixation of fractures was good. All patients were followed up 18-36 months (mean, 29 months). All fractures achieved bony union. The time of bony union was 16-23 weeks, with an average of 18.2 weeks. One patient (9.1%) got osteonecrosis of the femoral head (ONFH) at 30 months after operation. At last follow-up, Harris score was used to evaluate hip joint function, 9 cases were excellent, 1 case was good, 1 case was fair, and the excellent and good rate was 90.9%. Medial buttress plate augmented hollow lag screws fixation in combination with sartorius pedicled iliac flap for the treatment of femoral neck fractures in young adults has the advantage of strong biomechanical stability and can effectively improve the blood supply of femoral head and neck, which subsequently reduce the incidence of ONFH. However, the surgical indication should be fully considered.

Successful outcome of shell fractures in freshwater turtles treated with plate or screws and wire fixation techniques: 51 cases (2014-2019).

To evaluate the outcome of surgical fixation of shell fractures in rehabilitated wild freshwater turtles. 51 freshwater turtles with 86 shell fractures. The medical record database of a wildlife rehabilitation center in Wisconsin was searched from 2014 through 2019 for records of freshwater turtles with shell fractures repaired with a plate technique, screws and wire technique, or both. Signalment, fracture location, therapeutic approach (including the type of hardware used for repair), dry-docking duration, time to hardware removal, postremoval care, and outcome were evaluated. 36 of 51 (71%) turtles with shell fractures experienced successful fracture healing following surgical hardware fixation, and 33 (65%) were released. Shells of 38 (75%) turtles were repaired with plates only, 5 (10%) turtles with wire only, and 8 (16%) turtles with a combination of plates and screws and wires. Of the 51 turtles, 13 (25%) did not survive > 4 weeks following hardware repair, leaving 38 animals available to assess fracture healing. Median time to start staged removal was 42 days (range, 35 to 49 days) and to complete removal of the applied hardware was 56 days (range, 26 to 77 days). Complications associated with placement of the hardware occurred in 6 of 38 (16%) turtles. Complications included screw hole infection (4/38 [11%]), fracture necrosis (1/38 [3%]), and deep screw hole penetration (1/38 [3%]). Results indicated that shell fractures in freshwater turtles treated with surgical fixation techniques had a successful outcome. Most complications were minor, and fractures improved with time, resulting in acceptable fracture healing for release.

Are Bone Metabolism and Bone Material Strength Evaluations Worthwhile?: Commentary on an article by Tamara D. Rozental, MD, et al.: "Longitudinal Changes in Serum Markers of Bone Metabolism and Bone Material Strength in Premenopausal Women with Distal Radial Fracture".

Commentary The article by Dr. Tamara D. Rozental and colleagues introduces us to 2 innovative methods to improve our understanding of bone strength and fracture-healing biochemistry that maybe relevant to clinical practice. Bone mineral density (BMD) is the standard for determining bone quality and fracture risk but does not define the structural and mechanical properties of bone1. Impact microindentation provides information on the material properties of cortical bone that we as orthopaedic surgeons need in order to improve our choice of fixation strategy2. Markers of bone metabolism (MBM) have been used to assess the results of osteoporotic treatment but have not been applied to the non-osteoporotic patient to assess fracture healing or to predict potential osteoporosis3,4. Impact microindentation is a minimally invasive technique that measures the ability of the tibial cortex to resist a standardized impact force. This measures the bone’s material quality, which is the interaction of the bone’s mineral and organic elements to resist failure. This technique might allow for a better determination of the ability of bone to hold implants that are used for fracture fixation (for example, the ability to achieve screw purchase). A greater understanding of such variables would facilitate fixation decisions, including the potential need to augment fixation with use of locking screws or bone substitutes. In this study, the microindentation technique did not prove valuable in assessing bone quality, but the investigators demonstrated that the test was possible to administer in a clinical setting. MBM have demonstrated promise as markers of the healing response following the treatment of a fracture5. Sclerostin (a glycoprotein produced by osteocytes) and Dickkopf 1 (DKK1) both decrease bone formation were initially increased but then both dropped to low levels allowing the healing response to occur. Tartrate-resistant acid phosphatase (TRAP) and C-terminal telopeptide (both of which are indicators of osteoclastic activity) peaked early, indicating the need for bone removal secondary to fracture site necrosis. Bone-formation markers such as N-terminal extension propeptide of type-I collagen (P1NP) and bone-specific alkaline phosphatase (BSAP) increased throughout the healing phase. These longitudinal results are evidence that, in premenopausal women, the biochemistry of fracture healing can be evaluated. This study provides the impetus to evaluate whether MBM can determine problems in fracture healing earlier than radiographic evidence and also whether MBM can serve as an indication of early osteopenia and osteoporosis in premenopausal women6. This article had a number of strengths. Patient selection was appropriate (although it was limited to a specific group of premenopausal women with a distal radial fracture). The fractures were classified with use of an acceptable system that can be used to determine severity on the basis of the mechanism of injury (i.e., high or low energy). Finally, the study included both operatively and nonoperatively managed patients, with the former demonstrating an elevated BSAP. This article also had also several areas of concern. MBM vary depending on patient activity and the time of day when the samples are taken. The authors acknowledge this limitation, but it is important for the reader to understand that the controls were only sampled once, so any assumption regarding longitudinal MBM levels may not hold. Another issue is that there is no consensus on what constitutes a meaningful clinical difference in these results. As this study is the first to measure MBM during fracture healing, one is unsure of what these results mean. It is obvious that the results appear to coincide with our understanding of fracture healing, but this relationship has not been proven. Although this study has limitations, including a small sample size in a very specific patient population, it opens the door to a better understanding of fracture healing. Orthopaedic surgeons, particularly those specializing in fracture care, should consider this study as an impetus to further investigate the physiology and biochemistry of fracture healing.

Significant capabilities of SMART sensor technology and their applications for Industry 4.0 in trauma and orthopaedics

The Industry 4.0 revolution has made it possible for the manufacturing of newly customised implants, tools, devices instruments for the medical field. Sensor technology uses embedded or surface devices that detect physical, chemical, biological signals and provide a way of interpretation of these signals to be measured and recorded. Sensor technology products have been established in various branches of medicine. In healthcare these applications have been utilized in the diagnosis, treatment and monitoring of diseases. Innovations in computer and design technology have allowed researchers to expand sensor technology in the field of orthopaedic surgery. SMART (Self- Monitoring Analysis and Reporting Technology) implants along with Sensor technology have been developed to provide improved diagnostic and therapeutic functions in the management of a spectrum of musculoskeletal conditions. SMART implants have evolved due to the advances in microchip technologies. In this article we explore the role of Sensor technology in the branch of trauma and orthopaedics. Experimental studies, in-vivo and current clinical applications of Sensor technology in total hip replacement, total knee replacement, spine surgery, fracture healing assessment is highlighted. Overall the significant capabilities of Sensor technology can be utilized to improve patient satisfaction and functional scores whilst managing their orthopaedic conditions.

Implant Related Artifact Around Metallic and Bio-Integrative Screws: A CT Scan 3D Hounsfield Unit Assessment

Category:Basic Sciences/Biologics; HindfootIntroduction/Purpose:Implant-related artifact (IRA) represents an important limitation in Computed Tomography (CT) assessment of osteotomy and fracture healing, bone-implant integration, and success of fusion procedures. Metallic implants are the most used in foot and ankle surgery and are recognized as important IRA generators. Absorbable and bio-integrative (BI) implants are attractive options for bone fixation when postoperative CT imaging is likely, particularly in procedures with higher risk for nonunion. However, the literature comparing IRA with metallic and BI implants is scarce. The objective of this study was to assess the degree of IRA around metallic and BI cannulated screws. Our hypothesis was that BI implants would demonstrate significantly decreased IRA around the inserted screws.Methods:In this cadaveric/CT imaging study, 2 below-knee specimens were used. Medial displacement calcaneal osteotomy was performed through a 5-cm long lateral heel approach. Calcaneal tuberosity was displaced medially by 10mm and fixed provisionally with 2 parallel K-wires under fluoroscopic guidance. Specimens were fixed with two headless 4.0 millimeters cannulated screws, either metallic or BI. Cone-beam CT imaging of both specimens was acquired following osteotomy screw fixation (120kVp, 5.5mA, 0.25mm isotropic). Using a dedicated software, the overall dispersion of Hounsfield units (HU) in a 3D cube of 30mm edge length was assessed. Four HU lines were then traced parallel to the screws, crossing the osteotomy site. Lines 1, 2, 3 and 4 were positioned respectively: In close proximity, over, inside the cannulation and away from the implant. The HU dispersion in these lines was measured and compared between metallic and BI implanted specimens, using T-tests/Wilcoxon analysis. P-values<0.05 were considered significant.Results:When compared to the BI implant, the average HU was pronouncedly and significantly increased around metallic implants in the lines with more close proximity (Line 1), over the screw wall (Line 2) and inside the screw cannulation (Line 3), when considering both the whole line extension inside the 3D cube as well as in a selected 8mm line-segment across the calcaneal osteotomy line: Line 1 (entire, 7.26 vs -159; selected, -5 vs -249) Line 2 (entire, 4.846 vs 108; selected, 6286 vs 151.2); Line 3 (entire, 1664 vs 144; selected, -277.7 vs 198.7) selected). However, across Line 4 (away from the implant), the HU dispersion was interestingly and significantly decreased around the metallic implant (entire, -49 vs 178.5; selected, -110 vs 221), potentially as result of beam hardening artifact, concentrating HU close to the metal, and shielding the surrounding cancellous bone from being accurately reconstructed.Conclusion:In this cadaveric imaging study, we compared Implant-related artifact (IRA) around metallic and bio-integrative (BI) implants utilized to fix medial displacement calcaneal osteotomies. We found metallic implants to demonstrate significantly and pronouncedly increased HU dispersion in in close proximity with the implants and significantly decreased dispersion more distantly from the implant, shielding the surrounding cancellous bone, and potentially hindering the assessment of bone density quality and bone/osteotomy/fusion healing in its neighborhood. BI implants represent an alternative to decrease these IRA effects. Additional clinical studies are needed to confirm and expand our findings.

Functional assessment of long bone fracture healing in Samburu County Referral Hospital (Kenya): the squat and smile challenge.

Background:The burden of musculoskeletal trauma is increasing in low- and middle-income countries. Due to the low clinical follow-up rates in these regions, the Squat-and-Smile test (S&S) has previously been proposed as a proxy to assess bone healing (BH) capacity after surgery involving bone fractures. This study deals with various aspects of using S&S and bone radiography examination to obtain information about an individual's ability to recover after a trauma. In summary, we performed the S&S test to assess the possibility of recovering biomechanical function in lower limbs in a remote area of Kenya (Samburu County).Methods:Eighty-nine patients (17.9% F; 31.7 ± 18.9 yrs) who underwent intramedullary nail treatment for femur or tibia fractures were enrolled in this study. Both S&S [evaluated by a goal attainment scale (GAS)] and x-ray (evaluated by REBORNE, Bone Healing Score) were performed at 6 and 24 weeks, postoperatively. An acceptable margin for satisfactory S&S GAS scores was determined by assessing its validity, reliability, and sensitivity.Results:S&S GAS scores increased over time: 80.2% of patients performed a satisfactory S&S at the 24-weeks follow-up with a complete BH. A high correlation between S&S GAS and REBORNE at the 6- and 24- weeks’ timepoint was found. Facial expression correlated partially with BH. The S&S proved to be accurate at correctly depicting the BH process (75% area fell under the Receiver Operator Curve).Conclusion:The S&S provides a possible substitution for bone x-ray during BH assessment. The potential to remotely follow up the BH is certainly appealing in low- and middle-income countries, but also in high-income countries; as was recently observed with the Covid-19 pandemic when access to a hospital is not conceivable.

Sensitivity and specificity of modified RUST score using clinical and radiographic findings as a gold standard.

AimsThe modified Radiological Union Scale for Tibia (mRUST) fractures score was developed in order to assess progress to union and define a numerical assessment of fracture healing of metadiaphyseal fractures. This score has been shown to be valuable in predicting radiological union; however, there is no information on the sensitivity, specificity, and accuracy of this index for various cut-off scores. The aim of this study is to evaluate sensitivity, specificity, accuracy, and cut-off points of the mRUST score for the diagnosis of metadiaphyseal fractures healing.MethodsA cohort of 146 distal femur fractures were retrospectively identified at our institution. After excluding AO/OTA type B fractures, nonunions, follow-up less than 12 weeks, and patients aged less than 16 years, 104 sets of radiographs were included for analysis. Anteroposterior and lateral femur radiographs at six weeks, 12 weeks, 24 weeks, and final follow-up were separately scored by three surgeons using the mRUST score. The sensitivity and specificity of mean mRUST score were calculated using clinical and further radiological findings as a gold standard for ultimate fracture healing. A receiver operating characteristic curve was also performed to determine the cut-off points at each time point.ResultsThe mean mRUST score of ten at 24 weeks revealed a 91.9% sensitivity, 100% specificity, and 92.6% accuracy of predicting ultimate fracture healing. A cut-off point of 13 points revealed 41.9% sensitivity, 100% specificity, and 46.9% accuracy at the same time point.ConclusionThe mRUST score of ten points at 24 weeks can be used as a viable screening method with the highest sensitivity, specificity, and accuracy for healing of metadiaphyseal femur fractures. However, the cut-off point of 13 increases the specificity to 100%, but decreases sensitivity. Furthermore, the mRUST score should not be used at six weeks, as results show an inability to accurately predict eventual fracture healing at this time point.Cite this article: Bone Jt Open 2021;2(10):796–805.

CORRELATION OF BONE DENSITY AND OCCLUSO-MANDIBULAR PLANE ANGLE: A RETROSPECTIVE STUDY

<h3>BACKGROUND</h3> With a significant rise in the use of cone beam computed tomography (CBCT) and continuous evolution of newer applications, clinicians are increasingly using CBCT scans for bone density assessment using pixel intensity values (PIVs) while planning orthodontic treatment and in assessing fracture healing and dental implant sites. Several studies show that bone density increases with mandibular morphology and that patients with class III malocclusion have denser bone. <h3>OBJECTIVE(S)</h3> The objective of this study was to evaluate whether CBCT can determine relative differences in bone density among patients with different occluso-mandibular plane angles. <h3>STUDY DESIGN</h3> Retrospective evaluation of 300 CBCT scans of patients with different occluso-mandibular plane angles was performed. PIVs were measured with an area of 10 × 10 mm for different points of interest. The regions that were measured in the maxilla and the mandible were in the trabecular bone between the maxillary central incisors, between the first and second premolars, and mesial to the first molar, providing 6 points of interest. <h3>RESULTS</h3> The trabecular bone density between the central incisors in the maxilla was 527 and in the mandible it was 519 in the normodivergent group, 538 for the maxilla and 537 for the mandible in the hyperdivergent group, and 448 for the maxilla and 490 for the mandible in the hypodivergent group. Second premolars measured 331 for the maxilla and 408 for the mandible in the normodivergent group, 311 for the maxilla and 426 for the mandible in the hyperdivergent group, and 287 for the maxilla and 420 for the mandible in the hypodivergent group. The sites mesial to the left first molar measured 327 for the maxilla and 368 for the mandible in the normodivergent group, 285 for the maxilla and 354 for the mandible in the hyperdivergent group, and 289 for the maxilla and 389 for the mandible in hypodivergent group. <h3>DISCUSSION/CONCLUSIONS</h3> Data from this study show that PIVs are very similar in both maxillary and mandibular sites and cannot reliably discern bone density between groups with different occluso-mandibular plane angles.

Bony callus stiffness indirectly evaluated by the axial load-share ratio in vivo as a guide to removing a monolateral external fixator safely

PurposeAs the monolateral external fixator is increasingly used in trauma-control and definitive management for high-energy long bone fractures, timing the fixator removal remains a challenge for surgeons. The purpose of this study was to determine the feasibility and effectiveness of the bony callus stiffness indirectly evaluated by the axial load-share ratio in vivo as a guide to removing a monolateral external fixator safely.MethodsA total of 131 patients with tibial shaft fractures treated by the monolateral external fixator in our institution were collected from January 2013 to July 2019. In group I, the fixators were removed based on the clinical and radiological assessment only by the treating surgeon. As for group II, the axial load-share (LS) ratio test was accomplished by another medical team without the knowledge of the clinical results. The external fixator was removed when the mechanical test outcome (LS ratio < 10%) was consistent with the conclusion drawn from the clinical and radiological assessment (bone union achieved) by the treating surgeon.ResultsThere was no statistical significance in demographic data between the two groups (P > 0.05). In group I, four patients suffered refracture (the refracture rate was 7.7%) after fixator removal and were successfully treated by an intramedullary nail. In group II, 71 patients underwent fixator removal after the first mechanical test, and another eight patients terminated the external fixation after the second test. None of the 79 patients in group II suffered refracture (the refracture rate was 0%). There was statistical significance in the refracture rate between the two groups (P < 0.05).ConclusionThe bony callus stiffness indirectly evaluated by the axial load-share ratio in vivo using the additional circular frame components is an effectively quantitative indicator to complement the clinical assessment of fracture healing in a monolateral external fixation treatment. Removal of the monolateral external fixator is safe when the axial load-share ratio dropped below 10%.

English

BACKGROUND Trochanteric fractures are commonly encountered in elderly patients, and the outcome may be bad, if not intervened early. Dynamic hip screw (DHS) fixation is the most common treatment in stable trochanteric fracture. In unstable trochanteric fractures, there is high incidence of failure in view of excessive collapse seen with dynamic hip screw. In order to limit the collapse, we have done a modification on dynamic hip screw implant. Here we have assessed fracture healing, collapse and implant failure, in unstable trochanteric fractures (Evan’s unstable fractures) treated by modified dynamic hip screw fixation. METHODS The present retrospective case record analysis was conducted among 31 patients with unstable trochanteric fracture classified according to Evan’s classification who were operated with modified DHS in a tertiary care hospital. The details about fracture healing, collapse of fracture fragments, implant failure were assessed in a structured checklist through the case record analysis. RESULTS Out of 31 patients in this study, 29 patients showed fracture healing (93.5 %) with or without minimal collapse and 2 patients had non-union (6.5 %) at the end of 5 months follow up. Ultimately, all fractures united at the end of 1-year follow-up. Out of 31 patients in this study, at first month follow-up, 26 patients showed no implant failure (83.9 %), 5 patient had implant migration not breaching cortex (16.1 %), at third month follow-up, out of 5 patients who had implant migration, two patients had implant migration not breaching cortex (6.4 %), 3 patients had implant migration breaching cortex (11.0 %), at fifth month follow-up, two patients had implant migration not breaching cortex (6.4 %), 3 patients who had implant migration breaching cortex underwent revision surgery (11.0 %). CONCLUSIONS Modified dynamic hip screw has shown improved results as compared to normal dynamic hip screw in treating unstable trochanteric fracture, which limits the collapse at fracture site. KEYWORDS Unstable Trochanteric Fractures, Collapse, Modified Dynamic Hip Screw

Spatio-temporal characterization of fracture healing patterns and assessment of biomaterials by time-lapsed in vivo micro-computed tomography

Thorough preclinical evaluation of functionalized biomaterials for treatment of large bone defects is essential prior to clinical application. Using in vivo micro-computed tomography (micro-CT) and mouse femoral defect models with different defect sizes, we were able to detect spatio-temporal healing patterns indicative of physiological and impaired healing in three defect sub-volumes and the adjacent cortex. The time-lapsed in vivo micro-CT-based approach was then applied to evaluate the bone regeneration potential of functionalized biomaterials using collagen and bone morphogenetic protein (BMP-2). Both collagen and BMP-2 treatment led to distinct changes in bone turnover in the different healing phases. Despite increased periosteal bone formation, 87.5% of the defects treated with collagen scaffolds resulted in non-unions. Additional BMP-2 application significantly accelerated the healing process and increased the union rate to 100%. This study further shows potential of time-lapsed in vivo micro-CT for capturing spatio-temporal deviations preceding non-union formation and how this can be prevented by application of functionalized biomaterials. This study therefore supports the application of longitudinal in vivo micro-CT for discrimination of normal and disturbed healing patterns and for the spatio-temporal characterization of the bone regeneration capacity of functionalized biomaterials.