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3 RECOA meeting 2009
Low-intensity pulsed ultrasound
treatment of delayed unions andnonunions
Peter Nolte, MD PhD
Spaarne HospitalHoofddorp
The Netherlands
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Nonunion
Disturbed fracture healing
Localisation
6 - 9 months post-fracture = nonunion(pseudarthrosis)
1% of all fractures
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Nonunion
Definition:
failure bone healing
> 6 months andstop of all bone
healing processes
HypertrophicNormotrophic
Atrophic
8/6/2019 Low-intensity pulsed ultrasound for treatment of delayed unions and nonunions. Peter Nolte
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Nonunion
Cause?
Fracture (treatment) characteristics
Patient characteristics
8/6/2019 Low-intensity pulsed ultrasound for treatment of delayed unions and nonunions. Peter Nolte
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Nonunion
Operative treatment:
Stability
Healthy tissue
Sufficient bloodsupply
Concepts and Cases in Nonunion Treatment 2009
8/6/2019 Low-intensity pulsed ultrasound for treatment of delayed unions and nonunions. Peter Nolte
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Nonunion treatment
Surgery
stabilization
biomechanical
compression
Biological
invasive (Bone graft, BMP)
non-invasive (Shock wave, PEMF, LIPUS)
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LIPUS
Exogen device
Pulse width200ms
Pulsed at 1kHz
Frequency 1.5MHz
8/6/2019 Low-intensity pulsed ultrasound for treatment of delayed unions and nonunions. Peter Nolte
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LIPUS
Animal experiments
Ultrasound ControlNaruse et al J Bone Min Res 2003;18:360-9
8/6/2019 Low-intensity pulsed ultrasound for treatment of delayed unions and nonunions. Peter Nolte
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LIPUS
clinical trials fractures
Busse et al BMJ 2009;338:b351
8/6/2019 Low-intensity pulsed ultrasound for treatment of delayed unions and nonunions. Peter Nolte
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LIPUS
Animal nonunion study
Takikawa ea 2001
Rat tibia fracture and muscle interposition
LIPUS 50% (7/14) healing
Control 0% healing
8/6/2019 Low-intensity pulsed ultrasound for treatment of delayed unions and nonunions. Peter Nolte
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Nonunion LIPUS treatment
Nolte 2001 mixed 86% (25/29)
Fujioka 2004 hamate 100% (2/2)Gebauer 2005 mixed 85% (57/67)
Jones 2006 hindfoot 77% (13/18)
Jingushi 2007 mixed 75%(54/72)
Rutten 2007 tibia 73%(52/71)
8/6/2019 Low-intensity pulsed ultrasound for treatment of delayed unions and nonunions. Peter Nolte
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LIPUS in the treatment of
nonunionsProspective,
Non-randomized,
Case control study
Journal of Trauma 2001; 51(4):693-702
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LIPUS in the treatment of
nonunionsResults
Avg 5 months
25/29 healed (86%)
Journal of Trauma 2001; 51(4):693-702
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LIPUS in the treatment of
nonunions
Results
Analysis of 4 failures:-ankle arthrodesis for arthritis
-femur im nailing, healed after 1 year
-ulna plate, healed after 6 months
-scaphoid lost to follow up
Smoking, Instability,And Device compliance
Journal of Trauma 2001; 51(4):693-702
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Use of LIPUS for postraumaticnonunions of the tiba: a review of
patients treated in the Netherlands
Healing rate is 73%(52/71).
LIPUS - Spontaneous healing( p < 0.0001).
Stratification: no significant variable
Long-term follow-up
high compliance rate
no refractures.Journal of Trauma 2007; 62(4):902-8
8/6/2019 Low-intensity pulsed ultrasound for treatment of delayed unions and nonunions. Peter Nolte
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Osteotomy stimulation by
UltrasoundCorrection osteotomy
lower extremity
Double-blinded,clinical, randomizedstudy of lowintensity pulsedultrasound
Nolte PhD Thesis 2002
8/6/2019 Low-intensity pulsed ultrasound for treatment of delayed unions and nonunions. Peter Nolte
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Osteotomy stimulation by
UltrasoundResults
Baseline characteristics:
Age, gender,Osteotomy, smoking
Comparable
active - placebo
Nolte PhD Thesis 2002
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Osteotomy stimulation by
UltrasoundResults [weeks to consolidation]
Osteotomy Placebo Active
metaphysis 21 16
diaphysis 38 24
Total 28 19
(p
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Osteotomy stimulation by
UltrasoundResults
Baseline comparison of active placebo
Fibula OT
Nonunion development
Significant difference
Nolte PhD Thesis 2002
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LIPUS Treatment in Fibula
Nonunion
20 patients high tibial osteotomy
6 months fibula nonunion
Prospective randomized placebo controlledtrial
LIPUS/placebo 5 months
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LIPUS Treatment in Fibula
Nonunion
Acceleration of bone healing in fibula
nonunion
29%
Control
LIPUS
8/6/2019 Low-intensity pulsed ultrasound for treatment of delayed unions and nonunions. Peter Nolte
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LIPUS Treatment in Fibula
Nonunion
Fibula biopsy
3 months
LIPUS/placebo
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LIPUS increases bone volume, osteoidthickness and MAR in the area of bone
healing in patients with a delayed unionof the fibula
Histomorphometry
LIPUS accelerates clinical fracture healing byincreasing osteoblast activity. Direct boneformation was only observed in the LIPUS-treated delayed unions, which might beexplained by increased neovascularizationand/or stability.
Rutten et al Bone 2008;43:348-54
New Bone Cancellous bone Cortical bone
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LIPUS Treatment in
Nonunions
LIPUSPEMF
Clinical effect the same
LIPUS more evidence in RCT
LIPUS more easy to apply
8/6/2019 Low-intensity pulsed ultrasound for treatment of delayed unions and nonunions. Peter Nolte
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LIPUS Treatment in
Nonunions
Hypertrophic Nonunion --> stability
sometimes LIPUS
Normotrophic/Atrophic --> stability andbone graft
often LIPUS
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LIPUS Treatment in
Nonunions
Recognition of at risk patients
Combination with bone graft or BMP?
Evaluation of LIPUS treatment after
3 months