Sonographic bridging callus: An early predictor of fracture union

Nicholson, Jamie A; Oliver, William W.; LizHang, J; MacGillivray, Tom; Perks, Fergus; Robinson, C. M.; Simpson, A. H. R. W.

doi:10.1016/j.injury.2019.09.027

Cited by 21 publications

(18 citation statements)

References 32 publications

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“…Despite this promising research, ultrasound has not found a routine use in clinical practice, possibly due to its unfamiliarity for surgeons. We have recently published on a repeatable ultrasound technique, 10 and validated this on a cohort of displaced midshaft clavicle fractures where six week sonographic bridging callus predicted fracture healing in 98.6% of cases. 11 The ability to visualize the fracture site as a 3D reconstruction would enable clinicians unfamiliar with ultrasound to make their own judgement on the progression of callus.…”

Section: Discussionmentioning

confidence: 99%

“…Using the long axis ultrasound scout of the tibia, the cortical bone and callus surface can be identified due to the high homogeneity grayscale signal and linear border using an EI with a mean of 87.9 (95% confidence interval (CI) 83.5 to 92.3) as established in previous work. 10 EI is known to fluctuate from the depth of penetration of the ultrasound signal across the soft-tissue envelope, therefore a threshold above 80 was used to identify the desired surface with the Stradwin threshold tool, which was then plotted on sequential images by the reviewer (JAN) (Figure 1).…”

Section: Methodsmentioning

confidence: 99%

“…7-9 More recently, sonographic bridging callus on ultrasound has been described and shown to be strongly predictive of fracture healing for the clavicle. 10,11…”

Section: Introductionmentioning

confidence: 99%

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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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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

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3D ultrasound reconstruction of sonographic callus

Nicholson

Oliver

MacGillivray

et al. 2021

Bone & Joint Research

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“…Several imaging modalities have been proposed to estimate the status of the regenerative callus tissue, such as high-resolution magnetic resonance [20,21], quantitative ultrasound [22], dual-energy X-ray absorptiometry (DEXA) [11], and quantitative computed tomography (QCT) [12,23]. However, these alternative methods may involve large radiation doses, be restricted by cost and availability, or have not been assessed adequately for reliability.…”

Section: Discussionmentioning

confidence: 99%

The axial load-share ratio in vivo as a supplemental assessment for the external fixator safe removal

Liu

Jia

Cai

et al. 2021

Preprint

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Background: Timing the fixator removal is vital for a successful external fixation treatment. The purpose of this study was to determine the effectiveness of axial load-share ratio in vivo as a supplemental decision support tool for the safe removal of an Ilizarov external fixator.Methods: This prospective observational study consists of 83 patients undergoing tibial or femoral lengthening with Ilizarov circular external fixation in our institution, from January 2011 to October 2019. In group Ⅰ (38 patients), the external fixator was removed based on the surgeon’s clinical experience and radiographs from January 2011 to June 2015. In group Ⅱ (45 patients), from July 2015 to October 2019, the supplemental axial load-share (LS) ratio test was accomplished without the knowledge of the clinical results by another medical team. When the LS ratio < 10% was consistent with the conclusion (dense bone formation was achieved in the distraction zone) drawn from the corresponding routine radiographs by the treating surgeon, the external fixator was removed.Results: There was no statistical significance in demographic data between the two groups (P>0.05). In group Ⅰ, 4 of the 38 patients suffered refracture (the refracture rate was 10.5%) after fixator removal, and bone union was finally achieved with further intervention by intramedullary nail. In group Ⅱ, 36 patients terminated the external fixation after the first mechanical test, and another 9 patients terminated the external fixation at the subsequent test. None of the 45 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).Conclusions: Adequate assessment of bone regenerate is crucial before removing an external fixator to prevent deformation or refracture. The axial load-share ratio in vivo is a practically quantitative method to supplement radiography and clinical experience for the assessment of regenerate healing, and the axial load-share ratio dropped below 10% is a safe limit for the Ilizarov external fixator removal.

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“…It was shown that sonographic bridging callus at six weeks post-injury was a reliable finding between multiple observers with excellent accuracy to predict union at six months following non-operative management ( Fig. 3 ) [67] .…”

Section: Ultrasoundmentioning

confidence: 96%

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

Nicholson

Yapp

Keating

et al. 2021

Injury

Self Cite

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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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Sonographic bridging callus: An early predictor of fracture union

Cited by 21 publications

References 32 publications

3D ultrasound reconstruction of sonographic callus

3D ultrasound reconstruction of sonographic callus

The axial load-share ratio in vivo as a supplemental assessment for the external fixator safe removal

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

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