fracture healing thanks to: matthew porteous henry wynn jones mr lee van rensburg frcs basic...
TRANSCRIPT
![Page 1: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/1.jpg)
Fracture healing
Thanks to:Matthew PorteousHenry Wynn Jones
Mr Lee Van Rensburg
FRCS
Basic sciences course
2014
![Page 2: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/2.jpg)
FEBRUARY 2008 · VOLUME 90-A · SUPPLEMENT 1
![Page 3: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/3.jpg)
Subject Bone Structure - Done Indirect healing Direct healing Strain theory Blood supply Inhibition/ Augmentation What’s new? Approach to Non union
![Page 4: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/4.jpg)
Fracture Healing
Indirect healing (Secondary, Callus) Direct healing (Primary)
![Page 5: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/5.jpg)
Fracture Healing
Indirect healing (Secondary, Callus)
Formation of bone via tissues which undergo change in material
structure until skeletal continuity is restored
Direct healing (Primary)
![Page 6: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/6.jpg)
Indirect Fracture Healing
Impact
![Page 7: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/7.jpg)
Indirect Fracture Healing
Impact Haematoma
Haemopoetic cells secrete growth factors Fibroblasts, osteoprogenitor cells,
mesenchymal cells
![Page 8: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/8.jpg)
Indirect Fracture Healing
Impact Haematoma Inflammation
Granulation tissue 100% strain at failure
![Page 9: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/9.jpg)
Indirect Fracture Healing
Impact Haematoma Inflammation Soft Callus
2 weeks 10% strain at failure
![Page 10: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/10.jpg)
Indirect Fracture Healing
Impact Haematoma Inflammation Soft Callus Hard Callus
2% strain at failure
![Page 11: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/11.jpg)
Indirect Fracture Healing
Impact Haematoma Inflammation Soft Callus Hard Callus Remodeling
Years Wolff’s law
![Page 12: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/12.jpg)
Indirect Healing
time
strength
Movement at fracture site
![Page 14: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/14.jpg)
Perren’s Strain theory(interfragmentary strain theory) Interfragmentary strain determines the
subsequent differentiation of fracture gap tissue
10 to 100% fibrous tissue 2 to 10% - cartilage and enchondral
ossification < 2% - bone
![Page 15: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/15.jpg)
Indirect Healing - Movement
Movement is desirable Provided the movement does
not disrupt the healing cells10m 5m5m40m 10m
![Page 16: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/16.jpg)
Resorbtion
Small gap with movementHigh strain stimulates resorbtion
Resorbtion increases gap decreases strain
![Page 17: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/17.jpg)
Comminuted fragment
![Page 18: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/18.jpg)
Indirect Fracture Healing
![Page 19: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/19.jpg)
Intramembranous Osification(Periosteal boney callus)
Formation of bone on, or in, fibrous connective tissue(formed from condensed mesenchyme cells)
Vs
Enchondral ossificationHyaline cartilage first
![Page 20: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/20.jpg)
Direct Fracture Healing
Fracture stable No movement under physiological load
Bone ends compressed Can occur in cortical and cancellous bone
![Page 21: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/21.jpg)
Direct Fracture Healing
No callus Cutting cones cross
fracture site Lay down new
osteones directly
![Page 22: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/22.jpg)
Direct Healing
Movement Undesirable Even small amounts likely to disrupt
healing
![Page 23: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/23.jpg)
Absolute stability
![Page 24: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/24.jpg)
Wrong
![Page 25: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/25.jpg)
![Page 26: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/26.jpg)
Relative stability
![Page 27: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/27.jpg)
Complete instability
![Page 28: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/28.jpg)
Fractures MUST have a
blood supply to heal
![Page 29: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/29.jpg)
Bone blood supply
Endosteal Inner 2/3rds
Periosteal Outer 1/3rd
Disrupted by a fracture Further damaged by
surgery
![Page 30: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/30.jpg)
Bone blood supplyReaming
Damages endosteal blood supply
Blood flow reverses
BUT Stimulates callus
![Page 31: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/31.jpg)
Bone blood supply Plates
Damage periosteal blood supply
Causes underlying necrosis
![Page 32: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/32.jpg)
Bone blood supply - plates
Can be reduced by LCDCP Locking plate
![Page 33: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/33.jpg)
Augmentation of fracture healing
Inhibition Augmentation
![Page 35: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/35.jpg)
VOL. 89-B, No. 12, DECEMBER 2007
Inhibition Patient
Age - Some evidence (skeletally mature) Clavicle, NOF
Gender - No (male higher energy) Diabetes – Yes double time to union Anaemia – Some, Chronic iron defficiency Nutrition – If malnourished yes PVD – Not directly assesed but if injure vessel
40% longer to unite Hypothyroidism – Yes at risk Postmenopausal
female
![Page 36: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/36.jpg)
Inhibition Medication
NSAID
![Page 37: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/37.jpg)
VOLUME 88-A · SUPPLEMENT 3 · 2006
NSAIDs reduce vascularity around fracture.
Additional reduction in healing independent of blood flow.
Best to avoid in fractures prone to non union or poor vascularity.
![Page 38: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/38.jpg)
COX 2 NSAIDS inhibit fracture-healing more than non-specific NSAIDS.
Magnitude of effect is related to duration of treatment.
On discontinuation, prostaglandin E2 levels are gradually restored.
VOLUME 89-A · NUMBER 1 · JANUARY 2007
![Page 39: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/39.jpg)
Inhibition Medication
NSAID – Yes Corticosteroids – Appears to be longer Statins – Conflicting animal, no human?
beneficial Smoking – Yes for tibia 40% more likely non
union Nicotine replacement – conflicting high dose
no, low dose may improve, better than smoking Alcohol – Yes dose dependent
![Page 40: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/40.jpg)
Inhibition Medication
Antibiotics Quinolones Rifampicin High dose local Gentamycin
Anticoagulants (hep and warfarin) Yes animal model No human studies
Bisphosphonates
![Page 41: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/41.jpg)
Bisphosphonates – inhibit Osteoclasts.
Standard doses (osteoporosis), do not inhibit healing.
Do delay remodeling of callus. Higher doses eg. for Pagets or
metastatic bone disease not clear.
VOLUME 87-A · NUMBER 7 · JULY 2005
![Page 42: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/42.jpg)
Inhibition
Timing Viz NSAIDS and steroids more effect in
inflammatory phase
![Page 43: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/43.jpg)
Augmentation of fracture healing
Bone Grafts Bone Graft Substitutes Osteo-inductive agents Mechanical methods Ultrasound Electromagnetic fields
![Page 44: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/44.jpg)
Bone Graft Properties
Osteoconduction 3D scaffold
Osteo-induction Biological stimulus
Mesenchymal cells Osteoprogenitor cells
Osteogenic Contains living cells that
can differentiate to from bone
Structural
![Page 45: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/45.jpg)
![Page 46: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/46.jpg)
Osteo-inductive agents
Transforming growth factor Superfamily BMPs GDFs (growth differentiation factors) Possibly TGF-β 1, 2, and 3.
![Page 47: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/47.jpg)
Demineralized bone matrix
Acid extraction of allograft type-1 collagen non-collagenous proteins osteoinductive growth factors: BMP, GDFs,
TGF1,2 + 3
Different companies , processing differentALLOGRAFT, no reported infection transmission
![Page 48: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/48.jpg)
BMP 7 (OP-1)
Tibial non-unions RCT OP1 v autogenous graft No difference in union rate Less infections Friedlaender et al J Bone Joint Surg Am. 2001;83
Suppl 1(Pt 2):S151-8.
Open Tibia OP1 v control Less secondary interventions McKee et al Proceedings of the 18th Annual
Meeting of the Orthopaedic Trauma Association; 2002 Oct 11-13
![Page 49: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/49.jpg)
OP 1 653 cases, overall
success rate 82%
Injury, Int. J. Care Injured (2005) 36S, S47—S50
![Page 50: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/50.jpg)
BMP £ 3000 per vial Mean number of operations
Pre BMP 4.16 Post BMP 1.2
Hospital stay and cost Pre BMP 26.84 days and £ 13,844.68 Post BMP 7.8 days and £ 7338.40
Overall cost using BMP-7 - 47.0% less.
Injury, Int. J. Care Injured (2007) 38, 371—377
![Page 51: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/51.jpg)
BMP 2
BESTT Open tibial fractures
Control v 6mg v 12mg Higher dose
Fewer secondary procedures accelerated time to union improved wound-healing Reduced infection rateGovender et al Recombinant human bone morphogenetic protein-
2 for treatment of open tibial fractures: a prospective, controlled, randomized study of four hundred and fifty patients. J Bone Joint Surg Am. 2002;84:2123-34.
![Page 52: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/52.jpg)
Osteoconductive
Making the break. Karin Hing's fellowship has brought independence to pursue her work on bone graft substitutes.
![Page 53: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/53.jpg)
Osteoconductive RCT’s osteoconductive materials Vs autograft
encouraging. Calcium sulfate
Predictable resorption Resorbs a little too fast
Calcium phosphates Tricalcium phosphate TCP Hydroxyapatite TCP is more rapidly absorbed than hydroxyapatite,
TCP inadequate when structural support is desired Injectable osteoconductive cements
Several variations
![Page 54: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/54.jpg)
![Page 55: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/55.jpg)
Concentrated bone marrow aspirate
Non union – 75-95% success Aseptic non-unions
Only works if adequate cell concentration
Hernigou Pet al Influence of the number and concentration of progenitor cells. J Bone Joint Surg Am. 2005;87:1430 -7
Concentrated BM aspirate Ongoing multicentre RCT in
France Open tibial fractures
![Page 56: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/56.jpg)
Composite synthetic graft
Prospective multicenter RCT 249 long-bone #, min two years FU Bone graft v biphasic calcium phosphate mixed with
bovine collagen + autogenous bone marrow
No sig. diff. More infections with bone graft (22 v 9 p=0.008)
Chapman MW et al. Treatment of acute fractures with a collagen-calcium phosphate graft material. A randomized clinical trial. J Bone Joint Surg Am. 1997;79:495-502.
![Page 57: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/57.jpg)
Mechanical
Controlled axial micromotion Compression Distraction LIPUS Electromagnetic
![Page 58: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/58.jpg)
Controlled axial micromotion
Prospective RCT 102 tibial fractures 1.0 mm at 0.5 Hz /30 minutes per
day Sig. reduction
Time to union Secondary surgery
Kenwright J, Goodship AE. Controlled mechanical stimulation in the treatment of tibial fractures. Clin Orthop 1988;241:36-47.
![Page 59: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/59.jpg)
Low Intensity Ultrasound
Several RCTs Reduced time to union
Non-op tibia (No benefit in nailed #)
Scaphoids Impacted distal radius Jones
May reduce time to healing JW Busse et al. The effect of low-intensity pulsed ultrasound therapy
on time to fracture healing: a meta-analysis. Canadian Medical Association Journal 2002 166: 437-441
Sonic Accelerated Fracture Healing
System (SAFHS®) -Exogen 2000®
![Page 60: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/60.jpg)
Acute fractures with ultrasound Inconsistency in evidence ? Type II failure Available evidence supports the use of ultrasound in
the treatment of acute fractures of tibia and radius treated with plaster immobilization. (non op)
No benefit of LIPUS in the treatment of fractures of the tibia managed with intramedullary fixation.
J Trauma. 2008 Dec;65(6):1446-52
![Page 61: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/61.jpg)
Clinical relevance of any demonstrated effect is more difficult to justify.
Study may demonstrate a statistically significant effect of LIPUS, which may not be clinically relevant.
Overall low rate of nonunion in the studies raises the question of the usefulness of LIPUS in patients who have a fracture that is likely to heal anyway.
LIPUS therapy may be useful in patients with a potential for delayed union
complex fractures, significant comorbidities, smokers
J Trauma. 2008 Dec;65(6):1446-52
![Page 62: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/62.jpg)
Evidence for the effect of low intensity pulsed ultrasonography on healing of fractures is moderate to very low in quality and provides conflicting results.
Although overall results are promising, establishing the role of low intensity pulsed ultrasonography in the management of fractures requires large, blinded trials
BMJ. 2009; 338 b351
![Page 63: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/63.jpg)
Current evidence on the efficacy of low-intensity pulsed ultrasound to promote fracture healing is adequate to show that this procedure can reduce fracture healing time and gives clinical benefit, particularly in circumstances of delayed healing and fracture non-union.
There are no major safety concerns. Therefore this procedure may be used with normal
arrangements for clinical governance, consent and audit
![Page 64: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/64.jpg)
Electromagnetic Fields Exact Mechanism of action unknown Research suggests pulsed EM fields affect:
Encourages mineralisation Angiogenesis Increases DNA synthesis Alters the cellular calcium content in osteoblasts
EM fields can be generated:
Direct-current stimulation using implanted electrodes Inductive coupling produced by a time-varying
magnetic field Capacitative coupling
![Page 65: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/65.jpg)
Electromagnetic Fields Five methods for application of electromagnetic fields
Direct current (dc) delivered via a percutaneous cathode and an anode in contact with the skin
Direct current (dc) delivered by a completely implanted system
Capacitive coupled electric field (CCEF) through conductive plates attached to the skin.
Pulsed electromagnetic fields (PEMF) through externally applied coils which induce low level current
Combined electromagnetic fields (CMFs) which use both dynamic and static magnetic fields
![Page 66: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/66.jpg)
Electromagnetic devices
In vivo Osteoblasts BMP,TGFs, IGF
Small RCT 66% vs 0 healing of tibial non-unionScott G, King JB. A prospective double blind trial of electrical capacitive
coupling in the treatment of nonunion of long bones. J Bone Joint Surg [Am] 1994;76-A:820-6.
Several series 64-87% union of tibial non-union
![Page 67: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/67.jpg)
Small, methodologically limited trials with wide confidence intervals
Leaves impact of electromagnetic stimulation of fracture-healing uncertain.
Current evidence justifies neither enthusiastic dissemination nor confident rejection of this therapeutic modality.
Mollon B. et.al. J Bone Joint Surg 2008:90:2322-2330
![Page 68: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/68.jpg)
Clinically relevant treatment effect using electromagnetic stimulation.
Despite some methodological inconsistencies, the randomised trial evidence is consistent, and statistically significant.
Conclude - available evidence supports the use of electromagnetic stimulation in the treatment of non-union of the tibia.
Injury, Int. J. Care Injured (2008) 39, 419—429
![Page 69: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/69.jpg)
Whats new
VOL. 92-B, No. 3, MARCH 2010
G. Cox, T. A. Einhorn, C. Tzioupis, and P. V. Giannoudis
• BTM’s - Bone Turnover Markers• Metabolic bone disorders• Possible use in fracture prediction
• Delayed union• Non union
• Bone formation• Osteoblastic activity
• Bone resorption• Osteoclastic activity
![Page 70: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/70.jpg)
Whats new
VOL. 92-B, No. 3, MARCH 2010
G. Cox, T. A. Einhorn, C. Tzioupis, and P. V. Giannoudis
1. Bone-resorption markers2. Osteoclast regulatory proteins3. Bone-formation markers
3 Groups
![Page 71: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/71.jpg)
Whats new
VOL. 92-B, No. 3, MARCH 2010
G. Cox, T. A. Einhorn, C. Tzioupis, and P. V. Giannoudis
1. Bone-resorption markers2. Osteoclast regulatory proteins
• Factors involved with fusion of mononuclear osteoclast precursors to form mature multinucleated osteoclasts
• Factors include:• Receptor activator of nuclear factor NF-kB ligand
(RANKL)
• c-fms protooncogene• Modulation of osteoclastic activity is
controlled by: osteoprotegerin (OPG)
![Page 72: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/72.jpg)
Whats new
VOL. 92-B, No. 3, MARCH 2010
G. Cox, T. A. Einhorn, C. Tzioupis, and P. V. Giannoudis
1. Bone-resorption markers2. Osteoclast regulatory proteins3. Bone-formation markers
• Type-III collagen, is the initial collagen laid down during fracture healing and is replaced by type-I collagen to form bone.
![Page 73: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/73.jpg)
Whats new
VOL. 92-B, No. 3, MARCH 2010
G. Cox, T. A. Einhorn, C. Tzioupis, and P. V. Giannoudis
1. Bone-resorption markers2. Osteoclast regulatory proteins3. Bone-formation markers
• Hence markers of bone healing include fragments of type-I and type-III procollagen• Type-III collagen N-terminal propeptide, (PIIINP)• Type-I collagen C-terminal propeptide, (PICP)• Type-I collagen N-terminal propeptide (PINP)
• Specific measures of osteoblastic activity include :• Osteocalcin the major non-collagenous protein of bone
matrix• Bone-specific alkaline phosphatase (BSAP)
VOLUME 92-A d NUMBER 3 d MARCH 2010
![Page 74: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/74.jpg)
Whats new
VOL. 92-B, No. 3, MARCH 2010
G. Cox, T. A. Einhorn, C. Tzioupis, and P. V. Giannoudis
VOL 92-A ,No 3, MARCH 2010
![Page 75: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/75.jpg)
24 year old PVA Head injury Closed humeral shaft Radial nerve intact Humeral brace 6 months
Non union
![Page 76: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/76.jpg)
Non union approach
General Inhibition (smoking, NSAIDS)
Biology Mechanics (stability) Particular
Current Opinion in Orthopaedics 2006, 17:325–330
![Page 77: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/77.jpg)
Non union approach
General Biology
(atrophic vs hypertrophic) Open Infected Blood supply
Mechanics (stability) Particular
Current Opinion in Orthopaedics 2006, 17:325–330
![Page 78: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/78.jpg)
Non union approach
General Biology Mechanics (stability)
Brace (functional management) Plate Fixation Intramedullary Nail External fixation
Particular
Current Opinion in Orthopaedics 2006, 17:325–330
![Page 79: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/79.jpg)
Non union approach
General Biology Mechanics (stability) Particular
Acta Orthopaedica 2006; 77 (2): 279–284
![Page 80: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/80.jpg)
6 weeks 4 months
![Page 81: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/81.jpg)
4 months post injury
40 YO male High energy MVA Open grade 2 IM nail primary Rx
Non union 2
![Page 82: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/82.jpg)
Non union approach
General Biology
Atrophic (autograft) Avascular (nail – endosteal, cerclage periosteal) Open fracture ? Infection
Mechanics Instability No shelf viz compression (Biasetti II)
Particular No nail to nail
![Page 83: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/83.jpg)
10 months post injury Nail removed Plate
9 hole, LC-DCP SMALL FRAGMENT Proximal – 2 ?3 cortices Distal – 4? cortices
No growth
![Page 84: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/84.jpg)
Questions
www.easytrauma.co.ukwww.easytrauma.co.uk
![Page 85: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/85.jpg)
Questions Gap healing AO - Metaphyseal bone fairly rigidly fixed, no callous, no
cones but strain right to convert fibrous tissue to bone (get lucky)
Implant to bone gap and filling Defect (Gap) distraction osteogenesis
Electromagnetic stimulation
BMP in tissueInjury (2008) 39, 419—429
![Page 86: Fracture healing Thanks to: Matthew Porteous Henry Wynn Jones Mr Lee Van Rensburg FRCS Basic sciences course 2014](https://reader035.vdocuments.site/reader035/viewer/2022081520/56649ce35503460f949afae9/html5/thumbnails/86.jpg)