Is There an International Consensus as to How to Assess Fracture Healing Based on Clinical and Radiological Findings?

Session IV - Basic Science

Fri., 10/11/13 Basic Science, PAPER #55, 1:40 pm OTA 2013

Is There an International Consensus as to How to Assess Fracture Healing Based on Clinical and Radiological Findings?

Wojciech Glinkowski, MD, PhD1; Jakub Janowicz, MD1; Alexander N. Chelnokov, MD2;
1Department of Orthopaedics and Traumatology of Locomotor System, Center of Excellence
"TeleOrto" (Telediagnostics and Treatment of Disorders and Injuries of Locomotor System),
Medical University of Warsaw, Warsaw, Poland;
2Ural Scientific Research Institute of Traumatology and Orthopaedics, Ekaterinburg, Russia

Purpose: The lack of consensus and variability among orthopaedic surgeons in the assessment of fracture healing was reported in the literature. The aim of the study was to survey orthopaedic surgeons as to how they do this in clinical practice.

Methods: Orthopaedic surgeons/fracture researchers personally involved in fracture treatment were surveyed over the Internet. Personal e-mails containing an individual invitation to respond on the Internet-based survey were sent to 350 corresponding authors of articles published on fracture treatment. Additionally, an invitation was shared over orthopaedic trauma groups on social network portals. Eighty orthopaedic surgeons/researchers responded to the survey. We created an International Survey on Fracture Healing Assessment Methods through the survey portal (mini-ankiety.pl). The link to the survey was sent in every e-mail (http://www.mini-ankiety.pl/Survey/Take/30).

Results: The survey respondents came from 23 countries (Australia, Austria, Belarus, Canada, China, Colombia, France, Germany, Greece, India, Italy, Japan, Kazakhstan, Malaysia, Nigeria, Poland, Russia, Serbia, Sweden, Switzerland, Ukraine, USA, and Uzbekistan). Forty of them were Board-certified and forty during their residencies. The average age of respondents was 42.09 years (standard deviation 12.21). 83.75% consistently or ordinarily use specific clinical criteria to define a fracture union. Physical examination criteria are regularly or usually observed as follows: the absence of pain or tenderness on palpation, 87.50%; the absence of pain/tenderness when bearing weight, 95%; no pain/tenderness on examination, the ability to bear weight, 90%; and the ability to walk/perform activities of daily living with no pain, 82.50%. Any kind of fracture stiffness mechanical measurement is performed regularly or usually in 27%. Ultrasound propagation measurement, vibration analysis, impulse response analysis, or resonant frequency analysis are not performed in 67.5% to 85%. Radiographic modalities are constantly used by 92.5% of surveyed professionals. Surgeons rarely declared the regular use of advanced imaging technologies (CT - 7.5%, ultrasound - 6.25%, MRI - 5%, and scintigraphy - 3.75%). Interestingly, only 31.25% of international respondents always use AO/OTA fracture classification, 17.5% usually, 20% often, 18.75% sometimes, and hardly ever 12.5%. Semiquantitative scoring is seldom performed (7.5% - 8.75%). Bone densitometry (DEXA or QCT) is rarely used (11.25% and 16.25%, respectively).

Conclusion: Except for some recent approaches, fracture healing assessment studies remain semiquantitative and subjective due to the lack of consensus described in the orthopaedic literature and absent internationally proven quantitative methods. It is still not standardized in clinical practice as seen in this study. Further international incentives are mandatory to achieve a more standardized approach for valid and reliable clinical or radiological measures of the union, at least for the interpretation of fracture care trials. We have launched Spanish, Chinese, and Japanese versions of the survey already.

Funding: This study was supported by research grant N403 171340 from the National Science Centre.

Alphabetical Disclosure Listing

• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant.