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Ultraschall Med 2020; 41(01): 44-51
DOI: 10.1055/a-0637-1679
Original Article
© Georg Thieme Verlag KG Stuttgart · New York

Contrast-Enhanced Ultrasound (CEUS) Identifies Perfusion Differences Between Tibial Fracture Unions and Non-Unions

Kontrastmittelverstärkter Ultraschall (CEUS) zur Beurteilung der tibialen Knochenperfusion bei physiologischer und gestörter Frakturheilung mit Pseudarthrosenbildung
Christian Fischer
1   Center for Orthopedics, Trauma Surgery and Spinal Cord Injury. HTRG – Heidelberg Trauma Research Group, Heidelberg University Hospital, Heidelberg, Germany
,
Tabea Haug
1   Center for Orthopedics, Trauma Surgery and Spinal Cord Injury. HTRG – Heidelberg Trauma Research Group, Heidelberg University Hospital, Heidelberg, Germany
,
Marc-Andre Weber
2   Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
3   Institute of Diagnostic and Interventional Radiology, University Medical Center Rostock, Rostock, Germany
,
Hans-Ulrich Kauczor
2   Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
,
Thomas Bruckner
4   Institute of Medical Biometry and Informatics, University of Heidelberg, Germany
,
Gerhard Schmidmaier
1   Center for Orthopedics, Trauma Surgery and Spinal Cord Injury. HTRG – Heidelberg Trauma Research Group, Heidelberg University Hospital, Heidelberg, Germany
› Author Affiliations
Further Information

Publication History

10 January 2018

14 May 2018

Publication Date:
06 August 2018 (online)

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Contrast-Enhanced Ultrasound (CEUS) Identifies Perfusion Differences Between Tibial Fracture Unions and Non-UnionsUltraschall Med 2020; 41(01): e1-e1
DOI: 10.1055/a-0720-1610

Abstract

Purpose To assess the value of CEUS in the evaluation of tibial fracture perfusion and its ability to differentiate between physiologic and abnormal fracture healing.

Materials and Methods From 2014 to 2017, 107 patients with tibial fractures or tibial non-unions underwent CEUS examination. CEUS was performed at the regular follow-up examination 26 weeks after osteosynthesis or before non-union surgery. Time-intensity curves (TICs) of the contrast enhancement in the fracture gap were generated, and volume parameters such as wash-in rate (WiR), peak enhancement (PE) and wash-in perfusion index (WiPI) were quantified.

Results A total of 34 patients met the inclusion criteria of this study, including 14 consolidated fractures, 12 aseptic non-unions and 8 infected non-unions. WiR, PE and WiPI showed significantly lower values in aseptic non-unions compared to unions (p = 0.009, 0.009, 0.012, resp.). In contrast, infected non-unions showed higher values of WiR, PE and WiPI when compared to unions (p = 0.034, 0.056, 0.029, resp.).

Conclusion CEUS represents a feasible method in the assessment of tibial fracture perfusion. Perfusion differences between aseptic and infected tibial non-unions as well as healing tibial fractures could be detected. The deviation of physiologic fracture perfusion seems to be associated with disturbed osseous regeneration leading to non-union.

Zusammenfassung

Ziel Diese Studie untersuchte den Nutzen des CEUS für die Beurteilung verschiedener Perfusionsmuster nach Tibiafrakturen, die zur Ausheilung oder Pseudarthrosenbildung führen können.

Material und Methode Von 2014 bis 2017 wurde bei 107 Patienten mit Tibiafraktur oder Tibia-Pseudarthrose eine CEUS-Untersuchung durchgeführt. Die CEUS-Untersuchung fand zum regulären 26-Wochen Nachuntersuchungstermin statt, bei Patienten mit Pseudarthrose unmittelbar vor der Revisionsoperation. Es wurden Zeit-Intensitäts-Kurven der Kontrastmittelanflutung im Frakturspalt erstellt und quantitative Parameter wie „Wash-in Rate“ (WiR), „Peak Enhancement“ (PE) sowie „Wash-in Perfusion Index“ (WiPI) berechnet.

Ergebnisse 34 Patienten wurden eingeschlossen, davon 14 verheilte Frakturen, 12 aseptische Pseudarthrosen und 8 Infektpseudarthrosen. Die Perfusionsparameter WiR, PE and WiPI zeigten bei aseptischen Pseudarthrosen signifikant niedrigere Werte als bei verheilten Frakturen (p = 0,009; 0,009; 0,012). Im Gegensatz dazu waren WiR, PE and WiPI bei Infektpseudarthrosen höher als bei physiologisch verheilten Frakturen (p = 0,034; 0,056; 0,029).

Schlussfolgerung CEUS ist eine geeignete Methode zur Beurteilung der ossären Perfusion nach Fraktur. Im CEUS zeigen sich Perfusionsunterschiede von Tibiafrakturen mit regulärem Heilungsverlauf und solchen, die eine Pseudarthrose ausgebildet haben. Abweichungen von der physiologischen ossären Perfusion nach Tibiafraktur scheinen mit der Ausbildung einer Pseudarthrose zusammenzuhängen.

Key words

CEUS - fracture - non-union - tibia - osseus perfusion
 

  • References

  • 1 Bahney CS. et al. The multifaceted role of the vasculature in endochondral fracture repair. Front Endocrinol (Lausanne) 2015; 6: 4
    PubMedGoogle Scholar
  • 2 Giannoudis PV, Einhorn TA, Marsh D. Fracture healing: the diamond concept. Injury 2007; 38 (Suppl. 04) S3-S6
    PubMedGoogle Scholar
  • 3 Lu C, Marcucio R, Miclau T. Assessing angiogenesis during fracture healing. Iowa Orthop J 2006; 26: 17-26
    PubMedGoogle Scholar
  • 4 Giannoudis PV. et al. The diamond concept-open questions. Injury 2008; 39 (Suppl. 02) S5-S8
    CrossrefPubMedGoogle Scholar
  • 5 Murnaghan M, Li G, Marsh DR. Nonsteroidal anti-inflammatory drug-induced fracture nonunion: an inhibition of angiogenesis?. J Bone Joint Surg Am 2006; 88 (Suppl. 03) 140-147
    PubMedGoogle Scholar
  • 6 Calori GM. et al. Risk factors contributing to fracture non-unions. Injury 2007; 38 (Suppl. 02) S11-S18
    CrossrefPubMedGoogle Scholar
  • 7 Wiese A, Pape HC. Bone defects caused by high-energy injuries, bone loss, infected nonunions, and nonunions. Orthop Clin North Am 2010; 41: 1-4 , table of contents
    CrossrefPubMedGoogle Scholar
  • 8 Mills LA, Aitken SA, Simpson A. The risk of non-union per fracture: current myths and revised figures from a population of over 4 million adults. Acta Orthop 2017; 88: 434-439
    CrossrefPubMedGoogle Scholar
  • 9 Fong K. et al. Predictors of nonunion and reoperation in patients with fractures of the tibia: an observational study. BMC Musculoskelet Disord 2013; 14: 103
    CrossrefPubMedGoogle Scholar
  • 10 Brinker MR. et al. The devastating effects of tibial nonunion on health-related quality of life. J Bone Joint Surg Am 2013; 95: 2170-2176
    CrossrefPubMedGoogle Scholar
  • 11 O’Halloran K. et al. Will My Tibial Fracture Heal? Predicting Nonunion at the Time of Definitive Fixation Based on Commonly Available Variables. Clin Orthop Relat Res 2016; 474: 1385-1395
    CrossrefPubMedGoogle Scholar
  • 12 Moghaddam A. et al. Cigarette smoking influences the clinical and occupational outcome of patients with tibial shaft fractures. Injury 2011; 42: 1435-1442
    CrossrefPubMedGoogle Scholar
  • 13 Bhandari M. et al. Predictors of reoperation following operative management of fractures of the tibial shaft. J Orthop Trauma 2003; 17: 353-361
    CrossrefPubMedGoogle Scholar
  • 14 Schmidmaier G, Moghaddam A. Long Bone Nonunion. Z Orthop Unfall 2015; 153: 659-676
    Article in Thieme ConnectPubMedGoogle Scholar
  • 15 Bhandari M. et al. A lack of consensus in the assessment of fracture healing among orthopaedic surgeons. J Orthop Trauma 2002; 16: 562-566
    CrossrefPubMedGoogle Scholar
  • 16 Bishop JA. et al. Assessment of compromised fracture healing. J Am Acad Orthop Surg 2012; 20: 273-282
    CrossrefPubMedGoogle Scholar
  • 17 McClelland D. et al. Fracture healing assessment comparing stiffness measurements using radiographs. Clin Orthop Relat Res 2007; 457: 214-219
    CrossrefPubMedGoogle Scholar
  • 18 Augat P. et al. Imaging techniques for the assessment of fracture repair. Injury 2014; 45 (Suppl. 02) S16-S22
    CrossrefPubMedGoogle Scholar
  • 19 Fischer C. et al. Dynamic Contrast-Enhanced Sonography and Dynamic Contrast-Enhanced Magnetic Resonance Imaging for Preoperative Diagnosis of Infected Nonunions. J Ultrasound Med 2016; 35: 933-942
    CrossrefPubMedGoogle Scholar
  • 20 Geis S. et al. Quantitative assessment of bone microvascularization after osteocutaneous flap transplantation using contrast-enhanced ultrasound (CEUS). Ultraschall in Med 2013; 34: 272-279
    Article in Thieme ConnectPubMedGoogle Scholar
  • 21 Sidhu PS. et al. Role of Contrast-Enhanced Ultrasound (CEUS) in Paediatric Practice: An EFSUMB Position Statement. Ultraschall in Med 2017; 38: 33-43
    Article in Thieme ConnectPubMedGoogle Scholar
  • 22 Bhandari M. et al. Variability in the definition and perceived causes of delayed unions and nonunions: a cross-sectional, multinational survey of orthopaedic surgeons. J Bone Joint Surg Am 2012; 94: e1091-e1096
    PubMedGoogle Scholar
  • 23 Sun MH. et al. Three-dimensional high frequency power Doppler ultrasonography for the assessment of microvasculature during fracture healing in a rat model. J Orthop Res 2012; 30: 137-143
    CrossrefPubMedGoogle Scholar
  • 24 Schoierer O. et al. Dynamic contrast-enhanced magnetic resonance imaging can assess vascularity within fracture non-unions and predicts good outcome. Eur Radiol 2014; 24: 449-459
    CrossrefPubMedGoogle Scholar
  • 25 Caruso G. et al. Monitoring of fracture calluses with color Doppler sonography. J Clin Ultrasound 2000; 28: 20-27
    CrossrefPubMedGoogle Scholar
  • 26 Hamper UM. et al. Power Doppler imaging: clinical experience and correlation with color Doppler US and other imaging modalities. Radiographics 1997; 17: 499-513
    CrossrefPubMedGoogle Scholar
  • 27 Fischer C. et al. Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) for the prediction of non-union consolidation. Injury 2017; 48: 357-363
    CrossrefPubMedGoogle Scholar
  • 28 Verdonk R. et al. Biological methods to enhance bone healing and fracture repair. Arthroscopy 2015; 31: 715-718
    CrossrefPubMedGoogle Scholar
  • 29 Fischer C. et al. Dynamic contrast-enhanced ultrasound and elastography assess deltoid muscle integrity after reverse shoulder arthroplasty. J Shoulder Elbow Surg 2017; 26: 108-117
    CrossrefPubMedGoogle Scholar
  • 30 ter HaarG. Safety and bio-effects of ultrasound contrast agents. Med Biol Eng Comput 2009; 47: 893-900
    CrossrefPubMedGoogle Scholar