Author: TRUST Investigators writing group, Busse JW1,2,3, Bhandari M4,5, Einhorn TA6, Schemitsch E7, Heckman JD8, Tornetta P 3rd6, Leung KS9, Heels-Ansdell D4, Makosso-Kallyth S2, Della Rocca GJ10, Jones CB11, Guyatt GH4,12
Affiliation:
1Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, L8S 4K1, Canada bussejw@mcmaster.ca.
2Department of Anesthesia, McMaster University, Hamilton, ON L8S 4K1, Canada.
3Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON L8S 4K1, Canada.
4Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, L8S 4K1, Canada.
5Department of Surgery, McMaster University, Hamilton, ON L8S 4L8, Canada.
6Department of Orthopedic Surgery, NYU Langone Medical Center, New York, NY 10016, USA.
7Department of Surgery, University of Western Ontario, London, ON N6A 4V2, Canada.
8Department of Orthopedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03766, USA.
9Department of Orthopedics and Traumatology, Chinese University of Hong Kong, Shatin, Hong Kong, China.
10Department of Orthopedic Surgery, University of Missouri, Columbia, MO 65212, USA.
11Center for Orthopedic Research and Education, CORE, Banner University, Phoenix, AZ, 85023, USA.
12Department of Medicine, McMaster University, Hamilton, ON L8S 4K1, Canada.
Conference/Journal: BMJ.
Date published: 2016 Oct 25
Other:
Volume ID: 355 , Pages: i5351 , Special Notes: doi: 10.1136/bmj.i5351. , Word Count: 416
OBJECTIVE: To determine whether low intensity pulsed ultrasound (LIPUS), compared with sham treatment, accelerates functional recovery and radiographic healing in patients with operatively managed tibial fractures.
DESIGN: A concealed, randomized, blinded, sham controlled clinical trial with a parallel group design of 501 patients, enrolled between October 2008 and September 2012, and followed for one year.
SETTING: 43 North American academic trauma centers.
PARTICIPANTS: Skeletally mature men or women with an open or closed tibial fracture amenable to intramedullary nail fixation. Exclusions comprised pilon fractures, tibial shaft fractures that extended into the joint and required reduction, pathological fractures, bilateral tibial fractures, segmental fractures, spiral fractures >7.5 cm in length, concomitant injuries that were likely to impair function for at least as long as the patient's tibial fracture, and tibial fractures that showed <25% cortical contact and >1 cm gap after surgical fixation. 3105 consecutive patients who underwent intramedullary nailing for tibial fracture were assessed, 599 were eligible and 501 provided informed consent and were enrolled.
INTERVENTIONS: Patients were allocated centrally to self administer daily LIPUS (n=250) or use a sham device (n=251) until their tibial fracture showed radiographic healing or until one year after intramedullary fixation.
MAIN OUTCOME MEASURES: Primary registry specified outcome was time to radiographic healing within one year of fixation; secondary outcome was rate of non-union. Additional protocol specified outcomes included short form-36 (SF-36) physical component summary (PCS) scores, return to work, return to household activities, return to ≥80% of function before injury, return to leisure activities, time to full weight bearing, scores on the health utilities index (mark 3), and adverse events related to the device.
RESULTS: SF-36 PCS data were acquired from 481/501 (96%) patients, for whom we had 2303/2886 (80%) observations, and radiographic healing data were acquired from 482/501 (96%) patients, of whom 82 were censored. Results showed no impact on SF-36 PCS scores between LIPUS and control groups (mean difference 0.55, 95% confidence interval -0.75 to 1.84; P=0.41) or for the interaction between time and treatment (P=0.30); minimal important difference is 3-5 points) or in other functional measures. There was also no difference in time to radiographic healing (hazard ratio 1.07, 95% confidence interval 0.86 to 1.34; P=0.55). There were no differences in safety outcomes between treatment groups. Patient compliance was moderate; 73% of patients administered ≥50% of all recommended treatments.
CONCLUSIONS: Postoperative use of LIPUS after tibial fracture fixation does not accelerate radiographic healing and fails to improve functional recovery.Study registration ClinicalTrialGov Identifier: NCT00667849.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
PMID: 27797787
