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1980, British Journal of Radiology, 53, 863-868 SEPTEMBER 1980

New radioisotopic method for evaluation of the healingpotential of a fractureBy B. Basse -Cathal inat , Ph .D. , D. Ar na ud , Ph.D . , P. Blanq uet , M.D.Service de MSdecine Nucle aire, Hop ital P elleg rin, 33000 Bordea ux, FranceD. Ducassou, M.D.Service de Medecine Nucleaire, Hopital du Haut-Leveque, 33604 Pessac, Franceand P. Tram ond , Ph .D .Service de C hirurgie O rthoped ique, Hopital Pellegrin, 33000 Bordeaux, France{Received December 1978 and in revised form M arch 1980)

ABSTRACTA new radioisotopic method for the evaluation of thehealing potential of a fracture is developed in this paper.The centromedullary circulation in the bone is visualizedunder general anaesthesia by means of pertechnetate" T c m 04 injected into the distal metaphysis of the tibia.Twenty-two patients with an average age of 25 years havehad this examination. All suffered from a fracture of the legwith a worrying evolution.Isotopic osteomedullography has shown that the re-sumption of centromedullary circulation was the mostfavourable factor for good healing of the fracture. When theexamination is positive, it seems advisable to wait until thefocus is healed even if the clinical and/or radiographicsurvey are not in accordance, but when there is no resump-tion of the centromedullary circulation a pseudoarthrosismay well result. As the reliability of this technique issatisfactory, it should be used when doubt remains abouthealing of a fracture.The usual radiological techniques do not allow anobjective evaluation of the osteoblastic activity ofbone tissue; various investigations have been de-veloped, often by means of radioactive bone-seekingcompou nds, to detect the healing of a fracture focus(Bauer, 1968; Johansen , 197 3; Mu heim , 1973). Theuse of 85 Sr has shown that there was no definiterelation between the amount of the tracer fixed atthe level of the fracture and the evolution of thelatter. The physical characteristics of 8 7 S r m an d" T c m allow repeated examinations, particularly be-tween the 3rd and 30th week after the accident. Ithas been shown that the degree of fixation oftracer (87Srm or 99Tcm pyrophosphate) depends onthe vascular state of the focus. In order to appreciatewith only one investigation the likely evolution of afracture site, we have set up a new isotopic method ofexploration. This method is based on the work ofRhinelander (1968) who has pointed out theimportance of the centrom edullary circulation of thebone in osteogenesis and in the healing of fractures,and on the work of Puranen and Kaski (1974) whohave confirmed with an original radiological tech-nique the importance of resumption of the vascular

supply for the final healing of a fracture. The lattermethod could, however, be hard to interpret be-cause of the presence of orthopaedic material such asintramedullary rods. Also it seemed to us interestingto replace the product used for radiological contrastwith a labelled compound.MATERIALS AND METHODIsotopic osteomedullography consists in studyingthe centromedullary circulation of the bone with ascintillation camera equipped with a low-energy,high-resolution collimator and connected to a com-puter, after an injection of sodium pertechnetate( 9 9 T c m 04-) in the distal metaphysis of the fractured

tibia.The examination is performed under generalanaesthesia and strictly aseptic conditions with theleg lying on the collimator with the fracture site atthe centre; a trocar of Mallarme or Ficat type is putin the distal metaphysis of the tibia (2 to 4 cm abovethe ankle and within the anterior tibial muscle) aftera cuff has been placed at the level of the fracturefocus.After the segment below the fracture has beenpurged either with an Esmarch bandage or simplyby lifting and massaging the leg, the cuff intendedfor blocking the superficial circulation is pumped upto a pressure of 50 mm Hg , and 110 MB q (3 mCi) of99 rPc m04 contained in a volume of 3-4 ml of salineis injected in the distal metaphysis of the tibia fol-lowed by 15 ml of saline.With the computer coupled to the scintillationcamera the migration of the radioactive bolus in thecentromedullary circulation can be accuratelystudied. Before injection of the tracer, two series ofmeasurements are programmed. The first, per-formed with a tourniquet, consists in taking sequen-tial images every second for 100 seconds (the firstimage coinciding with the injection of the tracer);

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the second, without the tourniquet, allows thevenous circulation to return, the other parametersremaining the same.RESULTSTwenty-two fractures have been examined, 15TABLE I

CLASSIFICATION OF OPEN FRACTURES

Injury

O F -

r PI OAP1 OB +P3O AP 3 O B -P3 OBP2OB +P2OB +P1 O B -P 3 O B -P 3 O CP2OB +P2OB +P 3 O B -P3 OC^ P2O A

TreatmentPlasterNailingExternal fixationExternal fixationExternal fixationExternal fixationExternal fixationNailingExternal fixationExternal fixationPlatePlateExternal fixationExternal fixationPlate

Delay accident-scintigraphy4 months3.5 months6.5 months7 months6 months7 months12 months15 months8 months7 months13 months18 months6 months3 months9 months

TABLE IICLASSIFICATION OF CLOSED FRACTURES

Injury

CF

r P O O AP O O AP O O CP O O AP O O CP O O B -L P O O A

TreatmentPlasterCircleScrewExternal fixationNailing-[-screwPlatePlate

Delay accident -scintigraphy14 months4 months15 months8 months8 months12 months14 months

open fractures (Table I) and seven closed fractures(Table II), in patients with an average age of 25; wecan now consider all cases after an observationperiod of over 6 months. For one patient theinvestigation has been repeated three m onths later.The images obtained from the first series ofmeasurements show whether the tracer goes throughthe fracture focus or not. Zones of interest arechosen along the axis of the tibia and transit curvesof the radioactive bolus are plotted against time foreach zone. The examination is considered positive if,due to the resumption of the centromedullarycirculation, the "Tc m O4~ migrates through thefracture site. Th e exam ination is considered negativeif the tracer stagnates in the lower metaphy sis.Positive cases (Table III). There are 12 of these.Resumption of the centromedullary circulation isshown by the examination, so that no further thera-peutic action need be undertaken to attain finalhealing, even in the presence of ambiguous clinicaland/or radiological signs. Such is the case with the30-year-old patient show n in Fig. 1 who had beentreated for an open fracture of the leg by openoperation and nailing. Four months later, the patientstill walked with pain but with no frank support.Although X-ray tomography was doubtful theradioisotopic examination confirmed the resumptionof the centromedullary circulation. Subsequently,the fracture healed effectively.Negative cases (Table IV). There are ten of these,nine of w hich are comparable to the following obser-vation (Fig. 2). A 23-year-old man was injured withbilateral open comminuted fractures of the lowerlimbs and had been treated on both sides by align-ment nailing. Fifteen months later the fracture is

TABLE IIIANALYSIS OF POSITIVE CASES

Injury

o ,fP1 O A -P1 OB +P3 OAP 3 O B -P3O BP2O B +

OOOOO

oPPPMPMPH

fau

TreatmentPlasterNailingExternal fixationExternal fixationExternal fixationExternal fixationExternal fixationPlasterCircleScrewExternal fixationNailing + Screw

Delays of consolidationafter scintigraphicexamination45 days1 month1 month45 days1 month2 months2 months

02 months02 months0

Complementarytreatment

Plaster0PlasterDecorticationPlasterExternal fixationExternal fixation0External fixation0Plaster0


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SEPTEMBER 1980Ne w radioisotopic method for evaluation of the healing potential of a fracture

healed on the right side whereas walking is stillpainful on the left side. The isotopic examinationwas negative, in contradiction to the radiologicalsurvey, and the nail was removed and the presenceof a pseudoarthrosis confirmed. Permanent healingoccurred three months after reaming and the settingof a longer nail than the first one.In one case, when the isotopic osteomedullog-raphy was negative, healing of the fracture occurredsix months after the setting of external fixation withpermanent compression.

DISCUSSIONIn the presence of a simple closed fracture, or ofan open comminuted fracture which does not healwithin the usual time, the orthopaedic surgeon m ustbe able to distinguish between a simple delay inINJECTION

CF I G . 1.

Positive case (A) the tracer goes throu gh th e fracture;(B ) radiological aspect of pseudoarthrosis eight m onths afterthe fracture; (c) sometime later the healing is effective.865


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V O L . 53 , No . 633B. Basse-Cathalinat, D. Arnaud, P. Blanquet, D. Ducassou and P. Tramond

FRACTURE

INJECTION" 1 l P P i y * " .41l.'T'-r' I

cF I G . 2.Negative case, (A) the tracer stagnates in the lower meta-phy sis; (B ) nailing fracture. A doubt remains about thehealing of the fracture; (c) the presence of a pseudoarthrosisis confirmed after the nail is removed.

healing and an evolution towards a pseudoarthrosisrequiring a bone graft.Many studies have been undertaken with osteo-tropic radioisotopes to try to solve this problem.Most of them have been unhelpful. In fact, severalproblems are involved which limit the interest ofsuch investigations. First, the choice of the radio-nuclide which theoretically should be one of th eradioisotopes of calcium or phosphorous. Un-fortunately, the physical characteristics of theseradionuclides are not really convenient for scinti-graphy, and the conclusive phase of skeletal in-vestigation has started only with the use of 85 Sr,

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TABLE IVANALYSIS OF NEGATIVE CASES

InjuryfP1 OB-P3 O B -P 3 O CP2O B- rOv\ P2OB +| P3 O B -P3 OCLP2OA

f P O O B -[PO OA

TreatmentNailingExternal fixationExternal fixationPlatePlateExternal fixationExternal fixationPlatePlatePlate

ConfirmationpseudoarthrosisYYYN

YYYYYY

ComplementarytreatmentReaming + N ailingGraftGraftOsteotomy cf fibula+External fixationCancellous graftExternal fixationGraftCancellous graft

Graft + ExternalfixationReaming + Nailing

8 7S rm , 1 8 F, and now principally with phosphatecompounds labelled with " T c m , particularly 99Tcm-pyrophosphate. Whereas the general utility of thelatter is beyond doubt, its use for studies in repara-tive osteogenesis has been subject to some reser-vation, for it seems that calcium accretion at thelevel of the fracture focus does not correspond withit. The second difficulty encountered concerns theprognostic value of the ratio between the activitiesin the fractured and in the normal bone. A slightfixation of the radioactive product at the level of thefracture indicates indeed a deficient formation ofcallus, but in some pseudoarthrose s th e activity ratiois normal or even high (vascular pseudoarthrosis).Moreover, it is difficult to distinguish the fixation ofthe tracer at the level of the bone callus from thefixation due to some inflammatory process. Repeatedscintigraphic examinations between the 3rd and the30th week following the accident may be of someinterest, but will delay the answer for the ortho-paedic surgeon.

Analysis of the 23 fracture cases explored by iso-topic osteomedullography shows that resumption ofcentromedullary circulation of the bone is necessaryfor healing of a fracture. Among the 12 positiveexaminations, not a single false result has beenobserved. In all cases, the evolution of the focus hasappeared to be spontaneously favourable. Thus, anysurgical treatment of a pseudoarthrosis which wouldnot clear the medullary canals would be inefficient.Such was the case with a 31-year-old patient withan open fracture of the left leg which had requiredthe setting of a plate. Eight mo nths later a bone graftwas made, associated with external fixation. Thisintervention proved to be a failure. Eighteen months

later, in view of the hypervascular radiological aspectof the pseudoarthrosis, it was decided to perform anosteotomy of the fibula in spite of negative isotopicosteomedullography with permanent compression ofthe fracture focus by external fixation. Four monthslater, as healing was still not obtained, an inter-tibiofibular graft was carried out successfully.Howev er, in order to obtain healing of fractures, itis possible either to optimize the periosteal circu-lation (just with compression plating on the outsideof the bone or by Judet's decortication method) or toimprove the medullary circulation with a newreaming. The choice is given to the surgeon but wethink that non-resumption of medullary circulationexplains repeated fractures, for example after aPapineau operation.Among the negative examinations, nine were inconnection with an existing pseudoarthrosis. In onecase, the result of the radioisotopic examination wasrather d isturbing: a 23-year-old man with a B +type open fracture of the right leg was treated withexternal fixation. Seven months later a pseudo-arthrosis had developed at the level of the fractureand isotopic osteomedullography was negative. Anosteotomy of the fibula was then carried outassociated with permanent compression of thefracture focus by external fixation, and six monthslater the fracture healed. A further isotopic ex-amination was still negative. Thus, it seems that thestudy of the centromedullary circulation of thebone is not the only factor to be considered inevaluating the healing of a fracture focus.

REFERENCESBAUER, G., 1968. The use of radionuclides in orthopaedics-radio-nuclide scintimetry of the skeleton. Journal of Boneand Joint Surgery, 50-A, 1681 -1709.867


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JOHANSEN, A., 1973. Fracture healing controlled by 87 m Sr of osteomedullography in fractures of the tibial shaft,uptake. Ada orthopaedica scandinavica, 44 , 628-639. Journal of Bone and Joint Surgery, 56-A, 759-776.MUHEIM, G., 1973. Assessment of fracture healing in man RHINELANDER, F. W., 1968. The normal microcirculation ofby serial 87 mstrontium-scintimetry. Ada orthopaedica diaphyseal cortex and its response to fracture, Journal ofScandinavica, 44, 621 -627 . Bone and Joint Surgery, 50-A, 784-800.PURANEN, J., and KASKI, P., 1974. The clinical significance

Book reviewEinfiihrung in die Rontgendiagnostik. By Peter Thurn andEgon Bucheler, pp.ix+523, 1979 (German Text), (Thieme,Stuttgart), DM.84.ISBN 3-13-3160-060The fact that this is already the 6th edition since 1959would indicate that this "Introduction to RadiologicalDiagnosis" is very popular in the German-speaking world.The reasons for this are quite clear. The book is a veryhandy "quarto" format, beautifully produced with manyexcellent reproductions that even reproduce miliary tuber-culosis and silicosis. Ultrasound and computerized tomog-raphy are included in th e relevant sections.There are chapters on the physical basis of the techniquesused, radiology of the skeletal system, thorax, abdominalorgans, obstetrics and gynaecology, and soft tissues. Thereare very good tables indicating the radiation dose to thegonads and bone marrow for various examinations. Table 8,page 41 , compares the bone-marrow doses in Japan,Holland and Great Britain. Some of these figures makestrange reading and are hopefully incorrecta Dutchbarium swallow delivers 50 mrad to the bone marrow whilean Englishman gets a whacking 1300. Similar differencesexist for other examinations. These are very thought-provoking statistics.There are a few errors. Fig. 150, p. 141, supposedlyillustrating a Klippel Feil deformity of the neck, is aradiograph of the dorsal spine. Fig. 549, p.448, is a muchreproduced set of diagrams illustrating congenital renalabnormalities in which the terminations of duplex uretersare incorrectly placed.A m ore serious criticism is the lack of paediatric informa-tion. There are no illustrations of RDS, lobar emphysema,urethral valves, ureterocele in childhood, the importance ofmalrotation of the midgut, neonatal Hirschsprung'sdiseaseall matters of vital importance. Neuroradiology isnot discussed at all.The book fulfils its purpose as an introduction to radi-ology very well. It is up to date, clearly written and beauti-fully illustrated, and small enough to fit easily into a brief-case. G. M. STEINER.

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