Fractures of the distal radius : Factors related to radiographic evaluation, conservative treatment and fracture healing

Distal radius fractures (DRFs) are one of the most common injuries encountered in orthopaedic practise. Such fractures are most often treated conservatively, but surgical treatment has become increasingly common. This trend is not entirely scientifically based The aims of this thesis were threefold: to increase measurement precision in dorsal angulation (DA) on radiographs and computer tomographies (CTs); to assess the results after shortened plaster cast fixation time in reduced DRFs; and to evaluate the feasibility and safety of applying Augment® (rhPDGF-BB/β-TCP) in DRFs. In Paper I and Appendix 1 and 2, a semi-automatic CT-based three-dimensional method was developed to measure change in DA over time in DRFs. This approach proved to be a better (more sensitive) method than radiography in determining changes in DA in fractures of the distal radius. In Paper II, a CT model was used to simulate lateral radiographic views of different radial directions in relation to the X-ray. Using an alternative reference point on the distal radius, precision and accuracy in measuring DA was increased. Paper III and IV are based on a prospective and randomised clinical study (the GitRa trial) that compares clinical and radiographic outcomes after plaster cast removal at 10 days versus 1 month in 109 reduced DRFs. Three patients in the early mobilised group were excluded because of fracture dislocation (n=2) or a feeling of fracture instability (n=1). For the remaining patients in the early mobilised group (51/54) a limited but temporary gain in range of motion, but a slight increase in radiographic displacement were observed. Our results suggest that plaster cast removal at 10 days after reduction of DRFs is not feasible. Paper V is based on a prospective, randomised clinical study (the GEM trial) in which 40 externally fixated DRFs were randomised to rhPDGF-BB/β-TCP into the fracture gap or to the control group. Augment® proved to be convenient and safe during follow-up (24 weeks). However, because of the nature of the study design, the effect on fracture healing could not be determined. A decrease in pin infections was seen in the Augment® group, a finding we could not explain

Prospective randomized feasibility trial to assess the use of rhPDGF-BB in treatment of distal radius fractures

BACKGROUND: Recombinant human platelet-derived growth factor BB (rhPDGF-BB) combined with an osteoconductive scaffold (β-TCP) has been demonstrated to increase bone formation, but rhPDGF-BB has not been studied in human fractures. The purpose of this study was to evaluate the safety and potential use of locally administered rhPDGF-BB/β-TCP (Augment®) in acute wrist fractures. METHODS: Forty patients with unstable distal radial fracture were randomized to closed reduction and external fixation alone (n = 20) or combined with injection of rhPDGF-BB/β-TCP (Augment®) into the fracture (n = 20). All patients were followed for 24 weeks. Outcome was based on adverse events, fracture displacement on radiographs, fracture healing, range of motion, grip strength, pain, and the disability of the arm, shoulder and hand (DASH) score. RESULTS: There were no serious adverse events in the study, but the pin tract infection rate was significantly lower in the Augment® group. There was no difference between the groups in fracture healing time, based on number of healed cortices or fracture displacement. The Augment® group had an early temporary significant decrease in wrist flexion, but no difference in range of motion at 24 weeks. There were no differences between the two treatment groups for any other outcome variables. CONCLUSION: rhPDGF-BB/β-TCP (Augment®) is safe and convenient for local administration into wrist fractures. In this pilot study, we could not detect any reduced healing time in the Augment® group although potential efficacy should be addressed in larger studies. CLINICAL TRIAL REGISTRATION NUMBER: The clinical trial registration number for the study protocol is BMPI-2014-02-E

Prospective randomized feasibility trial to assess the use of rhPDGF-BB in treatment of distal radius fractures

BACKGROUND: Recombinant human platelet-derived growth factor BB (rhPDGF-BB) combined with an osteoconductive scaffold (β-TCP) has been demonstrated to increase bone formation, but rhPDGF-BB has not been studied in human fractures. The purpose of this study was to evaluate the safety and potential use of locally administered rhPDGF-BB/β-TCP (Augment®) in acute wrist fractures. METHODS: Forty patients with unstable distal radial fracture were randomized to closed reduction and external fixation alone (n = 20) or combined with injection of rhPDGF-BB/β-TCP (Augment®) into the fracture (n = 20). All patients were followed for 24 weeks. Outcome was based on adverse events, fracture displacement on radiographs, fracture healing, range of motion, grip strength, pain, and the disability of the arm, shoulder and hand (DASH) score. RESULTS: There were no serious adverse events in the study, but the pin tract infection rate was significantly lower in the Augment® group. There was no difference between the groups in fracture healing time, based on number of healed cortices or fracture displacement. The Augment® group had an early temporary significant decrease in wrist flexion, but no difference in range of motion at 24 weeks. There were no differences between the two treatment groups for any other outcome variables. CONCLUSION: rhPDGF-BB/β-TCP (Augment®) is safe and convenient for local administration into wrist fractures. In this pilot study, we could not detect any reduced healing time in the Augment® group although potential efficacy should be addressed in larger studies. CLINICAL TRIAL REGISTRATION NUMBER: The clinical trial registration number for the study protocol is BMPI-2014-02-E

Presurgical localization of infected avascular bone segments in chronic complicated posttraumatic osteomyelitis in the lower extremity using dual-tracer PET/CT.

BACKGROUND: Localizing and removing the infected sequestrum in long-standing trauma-related chronic osteomyelitis remains a clinical challenge. PET/CT with 18F-fluorodeoxyglucose (FDG-PET) has a high sensitivity for chronic osteomyelitis and 18F-sodium-fluoride PET/CT (NaF-PET) has a high specificity for identifying non-viable bone. Combining both, high signal on FDG-PET in the bone without signal on NaF-PET could potentially guide surgery to become more precise with curative intent. Eight patients with long-standing (average 22 years) posttraumatic (n = 7) or postoperative (n = 1) chronic osteomyelitis in the lower extremity and with multiple futile attempts for curative surgery were recruited in this prospective pilot study. FDG-PET and NaF-PET were performed within a week in between using standard scanning protocols. The most likely location of the culprit sequestrum was identified and was surgically removed. Based on perioperative tissue cultures, antibiotics were given for 6-8 months. Dual-tracer (FDG- and NaF-PET/CT) was performed again after 12 months to rule out persisting signs of infection. RESULTS: A likely culprit sequestrum could preoperatively be identified by dual-tracer PET in all eight cases and in four cases an additional sequestrum was identified at a location with no clinical sign of infection. The infected necrotic tissue was removed during surgery. Follow-up dual-tracer PET revealed no signs of persistent infection. All patients recovered with no clinical signs of recurrence for a follow-up of mean 4.5 (SD 1.3) years. CONCLUSIONS: Dual-tracer PET/CT with FDG and NaF allows successful precise surgery with curative intent in patients with long-standing complicated posttraumatic chronic osteomyelitis with severely deranged anatomy

Radiographic results after plaster cast fixation for 10 days versus 1 month in reduced distal radius fractures : a prospective randomised study

BACKGROUND: The aim of this study was to examine whether reduced distal radius fractures can be treated with early mobilisation without affecting the radiographic results. METHODS: In a prospective randomised study, 109 patients (mean age 65.8 (range 50-92)) with moderately displaced distal radius fractures were treated with closed reduction and plaster cast fixation for about 10 days (range 8-13 days) followed by randomisation to one of two groups: early mobilisation (n = 54, active group) or continued plaster cast fixation for another 3 weeks (n = 55, control group). RESULTS: For three patients in the active group (6%), treatment proved unsuccessful because of severe displacement of the fracture (n = 2) or perceived instability (n = 1). From 10 days to 1 month, i.e. the only period when the treatment differed between the two groups, the active group displaced significantly more in dorsal angulation (4.5°, p < 0.001), radial angulation (2.0°, p < 0.001) and axial compression (0.5 mm, p = 0.01) compared with the control group. However, during the entire study period (i.e. from admission to 12 months), the active group displaced significantly more than the controls only in radial angulation (3.2°, p = 0.002) and axial compression (0.7 mm, p = 0.02). CONCLUSIONS: Early mobilisation 10 days after reduction of moderately displaced distal radius fractures resulted in both an increased number of treatment failures and increased displacement in radial angulation and axial compression as compared with the control group. Mobilisation 10 days after reduction cannot be recommended for the routine treatment of reduced distal radius fractures. TRIAL REGISTRATION: ClinicalTrail.gov, NCT02798614 . Retrospectively registered 16 June 2016

Despite reductions in muscle mass and muscle strength in adults with CHD, the muscle strength per muscle mass relationship does not differ from controls

BACKGROUND: Patients with CHD exhibit reduced isometric muscle strength and muscle mass; however, little is known how these parameters relate. Therefore, the aim was to investigate the relation between isometric limb muscle strength and muscle mass for patients in comparison to age- and sex-matched control subjects. METHODS: Seventy-four patients (35.6 ± 14.3 years, women n = 22) and 74 matched controls were included. Isometric muscle strength in elbow flexion, knee extension, and hand grip was assessed using dynamometers. Lean mass, reflecting skeletal muscle mass, in the arms and legs was assessed with dual-energy x-ray absorptiometry. RESULTS: Compared to controls, patients had lower muscle strength in elbow flexion, knee extension, and hand grip, and lower muscle mass in the arms (6.6 ± 1.8 kg versus 5.8 ± 1.7 kg, p < 0.001) and legs (18.4 ± 3.5 kg versus 15.9 ± 3.2 kg, p < 0.001). There was no difference in achieved muscle force per unit muscle mass in patients compared to controls (elbow flexion 0.03 ± 0.004 versus 0.03 ± 0.005 N/g, p = 0.5; grip strength 0.008 ± 0.001 versus 0.008 ± 0.001 N/g, p = 0.7; knee extension 0.027 ± 0.06 versus 0.028 ± 0.06 N/g, p = 0.5). For both groups, muscle mass in the arms correlated strongly with muscle strength in elbow flexion (patients r = 0.86, controls, r = 0.89), hand grip (patients, r = 0.84, controls, r = 0.81), and muscle mass in the leg to knee extension (patients r = 0.64, controls r = 0.68). CONCLUSION: The relationship between isometric muscle strength and limb muscle mass in adults with CHD indicates that the skeletal muscles have the same efficiency as in healthy controls

Slower Skeletal Muscle Oxygenation Kinetics in Adults With Complex Congenital Heart Disease

Background: Adults with complex congenital heart disease (CHD) show reduced aerobic exercise capacity and impaired skeletal muscle function compared with healthy peers. Peripheral muscle factors are presumed to be important contributors to the aerobic capacity, but the mechanisms are poorly understood. The aim of the present study was to investigate differences between adults with CHD and controls in muscle oxygenation kinetics at rest, and during and after exercise. Methods: Seventy-four patients with complex CHD (mean age 35.6 ± 14.3 years, female n = 22) were recruited. Seventy-four age- and sex-matched subjects were recruited as controls. Muscle oxygenation was successfully determined on the anterior portion of the deltoid muscle using near-infrared spectroscopy in 65 patients and 71 controls. Measurements were made at rest, during isotonic shoulder flexions (0-90°) to exhaustion, and during recovery. Results: The patients with CHD performed fewer shoulder flexions (40 ± 17 vs 69 ± 40; P < 0.001), had lower muscle oxygen saturation (StO2) at rest (58 ± 18% vs 69 ± 18%; P < 0.001), slower desaturation rate at exercise onset (−9.7 ± 5.9 vs −15.1 ± 6.5% StO2 × 3.5 s−1, P <0.001), and slower resaturation rate post exercise (4.0 ± 2.7 vs 5.4 ± 3.6% StO2 × 3.5 s−1; P = 0.009) compared with the controls. Conclusions: In comparison with age- and sex-matched controls, adults with complex CHD had slower oxygenation kinetics. This altered skeletal muscle metabolism might contribute to the impaired skeletal muscle endurance capacity shown and thereby also to the reduced aerobic capacity in this population

Patients with complex congenital heart disease have slower calf muscle oxygenation during exercise

Background: Peripheral muscle factors are presumed to be contributors to the reduced exercise capacity incongenital heart disease (CHD), but the underlying mechanisms are poorly understood. The aim was to investigate if muscle oxygenation, at rest and during exercise, and the resting blood flow in the calf muscle is impaired in adults with complex CHD in comparison to controls. Method: Seventy-four adults with complex CHD (35.6 ± 14.3 years, females n = 22 [30%], males n = 52 [70%]) and seventy-four age and sex matched subjects were recruited. Muscle oxygenation was successfully determined using near-infrared spectroscopy on the medial portion of m. gastrocnemius in 63 patients and 67 controls. Measurements were made at rest, during venous occlusion to estimate blood flow (indicated by slope increase of total haemoglobin, HbT), and post arterial occlusion. Additionally, measurements were made at the onset of isotonic unilateral heel-lifts to exhaustion and during recovery post exercise. Results: Adults with CHD had a slower desaturation rate at exercise onset (-7.7 ± 4.3%StO2x3.5sec-1 vs. -11.7 ± 5.8%StO2x3.5sec-1, p &lt; 0.001) a slower half recovery time (28.6 ± 21.2s vs. 16.8 ± 11.1s, p &lt; 0.001) and a slower resaturation rate post exercise in comparison to the control subjects (3.9 ± 3.7%StO2x3.5sec-1 vs. 6.1 ± 3.8%StO2x3.5sec-1, p = 0.002). In contrast, there were no differences in muscle oxygen kinetics at rest. Conclusion: Slower muscle oxygenation kinetics during muscle exercise found in adults with complex CHD may give insight to the mechanisms for the reduced exercise capacity commonly found in this population. This finding may also provide implications for design of exercise training programs targeting muscle function for these patients

Forecasting effects of "fast-tracks" for surgery in the Swedish national guidelines for distal radius fractures

Background and purpose National guidelines for treatment of distal radius fractures (DRFs) were presented in Sweden in 2021. In the guidelines, a fast-track is recommended for 4 subgroups of highly unstable DRFs. Regardless of the results of the closed reduction these are recommended for surgery within 1 week of injury. This study aims to evaluate the potential consequences of the newly presented national guidelines on incidence of surgical interventions. Patients and methods In all, 1,609 patients (1,635 DRFs) with primary radiographs after a DRF between 2014 and 2017 at two Swedish hospitals were included in a retrospective cohort study. An estimation was made of the percentage of patients in the historical pre-guidelines cohort, that would have been recommended early primary surgery according to the new national guidelines compared to treatment implemented without the support of these guidelines. Results On a strict radiological basis, 32% (516 out of 1635) of DRFs were classified into one of the 4 defined subgroups. At 9-13 days follow-up, cast treatment was converted into delayed primary surgery in 201 cases. Out of these, 56% (112 out of 201) fulfilled the fast-track criteria and would with the new guidelines have been subject to early primary surgery. Interpretation The fast-track regimen in the new guidelines, has a high likelihood of identifying the unstable fractures benefitting from early primary surgery. If the proposed Swedish national guidelines for DRF treatment are implemented, a greater proportion of fractures would be treated with early primary surgery, and a delayed surgery avoided in the majority of cases. The potential benefits in relation to possible costs when using the fast-track criteria in every day practice are still unknown