The forgotten phase of fracture healing

Simpson, A. H. R. W.

doi:10.1302/2046-3758.610.bjr-2017-0301

Cited by 20 publications

(7 citation statements)

References 23 publications

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“…14 Therefore, due to the importance of preventing nonunions and delayed unions from occurring, promotion of fracture healing should be a priority in HTO surgery. 16…”

Section: Introductionmentioning

confidence: 99%

The effect of plate design, bridging span, and fracture healing on the performance of high tibial osteotomy plates

MacLeod

Serrancolí

Fregly

et al. 2018

Bone & Joint Research

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ObjectivesOpening wedge high tibial osteotomy (HTO) is an established surgical procedure for the treatment of early-stage knee arthritis. Other than infection, the majority of complications are related to mechanical factors – in particular, stimulation of healing at the osteotomy site. This study used finite element (FE) analysis to investigate the effect of plate design and bridging span on interfragmentary movement (IFM) and the influence of fracture healing on plate stress and potential failure.Materials and MethodsA 10° opening wedge HTO was created in a composite tibia. Imaging and strain gauge data were used to create and validate FE models. Models of an intact tibia and a tibia implanted with a custom HTO plate using two different bridging spans were validated against experimental data. Physiological muscle forces and different stages of osteotomy gap healing simulating up to six weeks postoperatively were then incorporated. Predictions of plate stress and IFM for the custom plate were compared against predictions for an industry standard plate (TomoFix).ResultsFor both plate types, long spans increased IFM but did not substantially alter peak plate stress. The custom plate increased axial and shear IFM values by up to 24% and 47%, respectively, compared with the TomoFix. In all cases, a callus stiffness of 528 MPa was required to reduce plate stress below the fatigue strength of titanium alloy.ConclusionWe demonstrate that larger bridging spans in opening wedge HTO increase IFM without substantially increasing plate stress. The results indicate, however, that callus healing is required to prevent fatigue failure.Cite this article: A. R. MacLeod, G. Serrancoli, B. J. Fregly, A. D. Toms, H. S. Gill. The effect of plate design, bridging span, and fracture healing on the performance of high tibial osteotomy plates: An experimental and finite element study. Bone Joint Res 2018;7:639–649. DOI: 10.1302/2046-3758.712.BJR-2018-0035.R1.

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“…14 Therefore, due to the importance of preventing nonunions and delayed unions from occurring, promotion of fracture healing should be a priority in HTO surgery. 16…”

Section: Introductionmentioning

confidence: 99%

The effect of plate design, bridging span, and fracture healing on the performance of high tibial osteotomy plates

MacLeod

Serrancolí

Fregly

et al. 2018

Bone & Joint Research

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“…3 Although CT may improve the accuracy of judging the cortical bridge, 20-23 it requires ionizing radiation and the timing at which callus can be found is likely similar to that of radiographs. 2…”

Section: Discussionmentioning

confidence: 99%

3D ultrasound reconstruction of sonographic callus

Nicholson

Oliver

MacGillivray

et al. 2021

Bone & Joint Research

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Aims The aim of this study was to establish a reliable method for producing 3D reconstruction of sonographic callus. Methods A cohort of ten closed tibial shaft fractures managed with intramedullary nailing underwent ultrasound scanning at two, six, and 12 weeks post-surgery. Ultrasound capture was performed using infrared tracking technology to map each image to a 3D lattice. Using echo intensity, semi-automated mapping was performed to produce an anatomical 3D representation of the fracture site. Two reviewers independently performed 3D reconstructions and kappa coefficient was used to determine agreement. A further validation study was undertaken with ten reviewers to estimate the clinical application of this imaging technique using the intraclass correlation coefficient (ICC). Results Nine of the ten patients achieved union at six months. At six weeks, seven patients had bridging callus of ≥ one cortex on the 3D reconstruction and when present all achieved union. Compared to six-week radiographs, no bridging callus was present in any patient. Of the three patients lacking sonographic bridging callus, one went onto a nonunion (77.8% sensitive and 100% specific to predict union). At 12 weeks, nine patients had bridging callus at ≥ one cortex on 3D reconstruction (100%-sensitive and 100%-specific to predict union). Presence of sonographic bridging callus on 3D reconstruction demonstrated excellent reviewer agreement on ICC at 0.87 (95% confidence interval 0.74 to 0.96). Conclusion 3D fracture reconstruction can be created using multiple ultrasound images in order to evaluate the presence of bridging callus. This imaging modality has the potential to enhance the usability and accuracy of identification of early fracture healing. Cite this article: Bone Joint Res 2021;10(12):759–766.

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“…There can be resistance to operate on a fracture that is slow to unite with some advocating waiting for the nonunion to 'declare' itself by approximately six to nine months. This has been described as the 'forgotten phase' of fracture healing that takes place between initial treatment decision and ultimate diagnosis of nonunion [9] .…”

Section: The Forgotten Phase Of Fracture Healing and Need For Early Recognitionmentioning

confidence: 99%

Monitoring of fracture healing. Update on current and future imaging modalities to predict union

Nicholson

Yapp

Keating

et al. 2021

Injury

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Fracture nonunion causes considerable patient morbidity and an associated burden to society. Traditional reliance on radiographs to monitor union has limitations as bridging callus of long bone fractures can take three or more months to occur. Computed Tomographic (CT) scanning is becoming increasingly popular and can evaluate bridging callus in the late stages of healing to confirm union. The use of dynamic contrast enhanced Magnetic Resonance Imaging (MRI) and advances in nuclear imaging may yield benefits in the assessment of the infected nonunion. Emerging evidence supports the use of ultrasound to detect bridging callus prior to radiographic confirmation and it may be of use to predict patients at high risk of nonunion.This paper is part of a Supplement supported by The Osteosynthesis and Trauma Care Foundation (OTCF).

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The forgotten phase of fracture healing

Cited by 20 publications

References 23 publications

The effect of plate design, bridging span, and fracture healing on the performance of high tibial osteotomy plates

The effect of plate design, bridging span, and fracture healing on the performance of high tibial osteotomy plates

3D ultrasound reconstruction of sonographic callus

Monitoring of fracture healing. Update on current and future imaging modalities to predict union

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