Qualitative and Quantitative Radiological Measures of Fracture Healing

Abstract

The formulation of appropriate postoperative strategies, following fracture repair, currently involves an understanding of radiological and clinical outcome measures. This study has evaluated several modalities used to assess the progression of bone healing in a sheep tibial segmental defect model. Measures of defect optical density and volumetric data including bone density (BD), bone volume (BV) and bone mass (BM) were compared with qualitative data involving visual appraisal of radiographs [% bridging callus and modified radiographic union score tibia (mRUST)] and a clinical outcome measure (locomotory function). Percent bridging callus and mRUST measures displayed strong correlation (r = 0.999), while locomotory function was weakly correlated with bridging callus (r = 0.029) and mRUST (r = 0.046). There was moderate to strong correlation between the qualitative and quantitative data. Bone density, BV and BM showed strong correlations within this dataset (BD–BV, r = 0.814; BD–BM, r = 0.818; BV–BM, r = 1.000). Likewise, optical density measures were strongly correlated with BD (r = 0.824), BV (r = 0.957) and BM (r = 0.959). The utilization of both qualitative and quantitative data, in assessment of the progression of fracture healing, has provided valuable insight. Measures of optical density have been shown to make a substantial contribution to this assessment and which should be considered for use in studies evaluating fracture healing.

Keywords

advanced imaging techniques - bone defect healing - animal models of human disease - comparative research - fracture repair

• References

• 1 McConnell S, Kolopack P, Davis AM. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC): a review of its utility and measurement properties. Arthritis Rheum 2001; 45 (05) 453-461
• 2 Nilsdotter A, Bremander A. Measures of hip function and symptoms: Harris Hip Score (HHS), Hip Disability and Osteoarthritis Outcome Score (HOOS), Oxford Hip Score (OHS), Lequesne Index of Severity for Osteoarthritis of the Hip (LISOH), and American Academy of Orthopedic Surgeons (AAOS) Hip and Knee Questionnaire. Arthritis Care Res (Hoboken) 2011; 63 (Suppl. 11) S200-S207
• 3 Field JR, Schnurr D, Horney FD. Evaluation of an instrumented horseshoe system. Vet Comp Orthop Traumatol 1992; 19: 58-64
• 4 Kaler J, Wassink GJ, Green LE. The inter- and intra-observer reliability of a locomotion scoring scale for sheep. Vet J 2009; 180 (02) 189-194
• 5 Augat P, Morgan EF, Lujan TJ, MacGillivray TJ, Cheung WH. Imaging techniques for the assessment of fracture repair. Injury 2014; 45 (Suppl. 02) S16-S22
• 6 Field JR, McGee M, Wildenauer C, Kurmis A, Margerrison E. The utilization of a synthetic bone void filler (JAX) in the repair of a femoral segmental defect. Vet Comp Orthop Traumatol 2009; 22 (02) 87-95
• 7 Field JR, McGee M, Stanley R. , et al. The efficacy of allogeneic mesenchymal precursor cells for the repair of an ovine tibial segmental defect. Vet Comp Orthop Traumatol 2011; 24 (02) 113-121
• 8 den Boer FC, Patka P, Bakker FC. , et al. New segmental long bone defect model in sheep: quantitative analysis of healing with dual energy x-ray absorptiometry. J Orthop Res 1999; 17 (05) 654-660
• 9 Reichert JC, Epari DR, Wullschleger ME. , et al. Establishment of a preclinical ovine model for tibial segmental bone defect repair by applying bone tissue engineering strategies. Tissue Eng Part B Rev 2010; 16 (01) 93-104
• 10 Gao C, Seuntjens J, Kaufman GN. , et al. Mesenchymal stem cell transplantation to promote bone healing. J Orthop Res 2012; 30 (08) 1183-1189
• 11 Christou C, Oliver RA, Pelletier MH, Walsh WR. Ovine model for critical-size tibial segmental defects. Comp Med 2014; 64 (05) 377-385
• 12 Whelan DB, Bhandari M, Stephen D. , et al. Development of the radiographic union score for tibial fractures for the assessment of tibial fracture healing after intramedullary fixation. J Trauma 2010; 68 (03) 629-632
• 13 Bhandari M, Guyatt GH, Swiontkowski MF, Tornetta III P, Sprague S, Schemitsch EH. A lack of consensus in the assessment of fracture healing among orthopaedic surgeons. J Orthop Trauma 2002; 16 (08) 562-566
• 14 Whelan DB, Bhandari M, McKee MD. , et al. Interobserver and intraobserver variation in the assessment of the healing of tibial fractures after intramedullary fixation. J Bone Joint Surg Br 2002; 84 (01) 15-18
• 15 Barnes K, Lanz O, Were K. , et al. Comparison of autogenous cancellous bone grafting and extra-corporeal shock wave therapy on osteotomy healing in the tibial tuberosity advancement procedure in dogs. Radiographic densitometric evaluation. Vet Comp Orthop Traumatol 2015; 28 (03) 207-214
• 16 Filho LA, Primo BT, Gassen HT. , et al. Evaluation of optical density of bone defects filled with calcium phosphate cement and bioactive glass in rats. Acta Cir Bras 2011; 26 (11) 1-6
• 17 Souza TF, Andrade AL, Ferreira GT. , et al. Healing and expression of growth factors (TGF-β and PDGF) in canine radial ostectomy gap containing platelet-rich plasma. Vet Comp Orthop Traumatol 2012; 25 (06) 445-452
• 18 Farinazzo CS, Iwaki LC, Filho LI. , et al. Optical density evaluation around the zirconia granules used as graft in rat calvaria. Acta Scientiarum 2014; 36 (02) 265-272
• 19 Janic J, Mijovic Z, Mihailovic D. , et al. Optical density of cortical bone matrix is diminished in experimentally induced osteoporosis. Acta Medica Medianae 2016; 55 (02) 35-39
• 20 Pekkan G, Aktas A, Pekkan K. Comparative radiopacity of bone graft materials. J Craniomaxillofac Surg 2012; 40 (01) e1-e4
• 21 Grassl U, Schulze RK. In vitro perception of low-contrast features in digital, film, and digitized dental radiographs: a receiver operating characteristic analysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 103 (05) 694-701
• 22 Ostlere SJ, Gold RH. Osteoporosis and bone density measurement methods. Clin Orthop Relat Res 1991; (271) 149-163
• 23 Watts DC, McCabe JF. Aluminium radiopacity standards for dentistry: an international survey. J Dent 1999; 27 (01) 73-78
• 24 Lujan TJ, Madey SM, Fitzpatrick DC, Byrd GD, Sanderson JM, Bottlang M. A computational technique to measure fracture callus in radiographs. J Biomech 2010; 43 (04) 792-795
• 25 Lujan TJ, Henderson CE, Madey SM, Fitzpatrick DC, Marsh JL, Bottlang M. Locked plating of distal femur fractures leads to inconsistent and asymmetric callus formation. J Orthop Trauma 2010; 24 (03) 156-162
• 26 Henderson CE, Lujan TJ, Kuhl LL, Bottlang M, Fitzpatrick DC, Marsh JL. 2010 mid-America Orthopaedic Association Physician in Training Award: healing complications are common after locked plating for distal femur fractures. Clin Orthop Relat Res 2011; 469 (06) 1757-1765
• 27 Chehade MJ, Solomon LB, Callary SA, Benveniste SH, Pohl AP, Howie DW. Differentially loaded radiostereometric analysis to monitor fracture stiffness: a feasibility study. Clin Orthop Relat Res 2009; 467 (07) 1839-1847
• 28 Solomon LB, Stevenson AW, Callary SA, Sullivan TR, Howie DW, Chehade MJ. The accuracy and precision of radiostereometric analysis in monitoring tibial plateau fractures. Acta Orthop 2010; 81 (04) 487-494
• 29 Chehade MJ, Vakaci IA, Callary SA. , et al. Differentially loaded radiostereometric analysis (DLRSA) in torsion adds essential information in diaphyseal bone healing: the example of a tibial osteotomy. J Bioeng Biomed Sci 2011; 1: 1-5
• 30 Cohen J. A coefficient of agreement for nominal scales. Educ Psychol Meas 1960; 20 (01) 37-46