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

SEPTEMBER 1980

New radioisotopic method for evaluation of the healing potential of a fracture

By B. Basse-Cathalinat, Ph.D., D. Arnaud, Ph.D., P. Blanquet, M.D. Service de MSdecine Nucleaire, Hopital Pellegrin, 33000 Bordeaux, France D. Ducassou, M.D. Service de Medecine Nucleaire, Hopital du Haut-Leveque, 33604 Pessac, France and P. Tramond, Ph.D. Service de Chirurgie Orthopedique, Hopital Pellegrin, 33000 Bordeaux, France {Received December 1978 and in revised form March 1980)
ABSTRACT

A new radioisotopic method for the evaluation of the healing potential of a fracture is developed in this paper. The centromedullary circulation in the bone is visualized under general anaesthesia by means of pertechnetate "Tc m 04 injected into the distal metaphysis of the tibia. Twenty-two patients with an average age of 25 years have had this examination. All suffered from a fracture of the leg with a worrying evolution. Isotopic osteomedullography has shown that the resumption of centromedullary circulation was the most favourable factor for good healing of the fracture. When the examination is positive, it seems advisable to wait until the focus is healed even if the clinical and/or radiographic survey are not in accordance, but when there is no resumption of the centromedullary circulation a pseudoarthrosis may well result. As the reliability of this technique is satisfactory, it should be used when doubt remains about healing of a fracture.

supply for the final healing of a fracture. The latter method could, however, be hard to interpret because of the presence of orthopaedic material such as intramedullary rods. Also it seemed to us interesting to replace the product used for radiological contrast with a labelled compound.
MATERIALS AND METHOD

The usual radiological techniques do not allow an objective evaluation of the osteoblastic activity of bone tissue; various investigations have been developed, often by means of radioactive bone-seeking compounds, to detect the healing of a fracture focus (Bauer, 1968; Johansen, 1973; Muheim, 1973). The use of 85Sr has shown that there was no definite relation between the amount of the tracer fixed at the level of the fracture and the evolution of the latter. The physical characteristics of 8 7 Sr m and " T c m allow repeated examinations, particularly between the 3rd and 30th week after the accident. It has been shown that the degree of fixation of tracer ( 87 Sr m or 99Tcm pyrophosphate) depends on the vascular state of the focus. In order to appreciate with only one investigation the likely evolution of a fracture site, we have set up a new isotopic method of exploration. This method is based on the work of Rhinelander (1968) who has pointed out the importance of the centromedullary circulation of the bone in osteogenesis and in the healing of fractures, and on the work of Puranen and Kaski (1974) who have confirmed with an original radiological technique the importance of resumption of the vascular

Isotopic osteomedullography consists in studying the centromedullary circulation of the bone with a scintillation camera equipped with a low-energy, high-resolution collimator and connected to a computer, after an injection of sodium pertechnetate ( 99 Tc m 04-) in the distal metaphysis of the fractured tibia. The examination is performed under general anaesthesia and strictly aseptic conditions with the leg lying on the collimator with the fracture site at the centre; a trocar of Mallarme or Ficat type is put in the distal metaphysis of the tibia (2 to 4 cm above the ankle and within the anterior tibial muscle) after a cuff has been placed at the level of the fracture focus. After the segment below the fracture has been purged either with an Esmarch bandage or simply by lifting and massaging the leg, the cuff intended for blocking the superficial circulation is pumped up to a pressure of 50 mm Hg, and 110 MBq (3 mCi) of 99rPcm04 contained in a volume of 3-4 ml of saline is injected in the distal metaphysis of the tibia followed by 15 ml of saline. With the computer coupled to the scintillation camera the migration of the radioactive bolus in the centromedullary circulation can be accurately studied. Before injection of the tracer, two series of measurements are programmed. The first, performed with a tourniquet, consists in taking sequential images every second for 100 seconds (the first image coinciding with the injection of the tracer);

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53, No. 633 B. Basse-Cathalinat, D. Arnaud, P. Blanquet, D. Ducassou and P. Tramond open fractures (Table I) and seven closed fractures (Table II), in patients with an average age of 25; we can now consider all cases after an observation period of over 6 months. For one patient the investigation has been repeated three months later. The images obtained from the first series of measurements show whether the tracer goes through the fracture focus or not. Zones of interest are chosen along the axis of the tibia and transit curves of the radioactive bolus are plotted against time for each zone. The examination is considered positive if, due to the resumption of the centromedullary circulation, the "Tc m O4~ migrates through the fracture site. The examination is considered negative if the tracer stagnates in the lower metaphysis. Positive cases (Table III). There are 12 of these. Resumption of the centromedullary circulation is shown by the examination, so that no further therapeutic action need be undertaken to attain final healing, even in the presence of ambiguous clinical and/or radiological signs. Such is the case with the 30-year-old patient shown in Fig. 1 who had been treated for an open fracture of the leg by open operation and nailing. Four months later, the patient still walked with pain but with no frank support. Although X-ray tomography was doubtful the radioisotopic examination confirmed the resumption of the centromedullary circulation. Subsequently, the fracture healed effectively. Negative cases (Table IV). There are ten of these, nine of which are comparable to the following observation (Fig. 2). A 23-year-old man was injured with bilateral open comminuted fractures of the lower limbs and had been treated on both sides by alignment nailing. Fifteen months later the fracture is

the second, without the tourniquet, allows the venous circulation to return, the other parameters remaining the same.
RESULTS

Twenty-two fractures have been examined, 15

TABLE I
CLASSIFICATION OF OPEN FRACTURES

Injury

Treatment Plaster Nailing External fixation External fixation External fixation External fixation External fixation Nailing External fixation External fixation Plate Plate External fixation External fixation Plate

Delay accidentscintigraphy 4 months 3.5 months 6.5 months 7 months 6 months 7 months 12 months 15 months 8 months 7 months 13 months 18 months 6 months 3 months 9 months

PI OA

P1 OB + P3OA P3OBP3 OB
OF-

P1 O B P3OBP3OC P3OBP3 OC ^ P2OA

P2OB + P2OB +

P2OB + P2OB +

TABLE II
CLASSIFICATION OF CLOSED FRACTURES

Injury POOA POOA POOC CF<! POOA POOC POOBL POOA

r

Treatment Plaster Circle Screw External fixation Nailing-[-screw Plate Plate

Delay accident scintigraphy 14 months 4 months 15 months 8 months 8 months 12 months 14 months

TABLE III
ANALYSIS OF POSITIVE CASES

Injury fP1 O A P1 OB + P3 OA P3OBP3OB P2OB +

Treatment Plaster Nailing External fixation External fixation External fixation External fixation External fixation Plaster Circle Screw External fixation Nailing + Screw

Delays of consolidation after scintigraphic examination 45 days 1 month 1 month 45 days 1 month 2 months 2 months 0 2 months 0 2 months 0

Complementary treatment Plaster 0 Plaster Decortication Plaster External fixation External fixation 0 External fixation 0 Plaster 0

o,

ooooo

PL,PH PMPMPH

OOOOO

fa

SEPTEMBER 1980

New radioisotopic method for evaluation of the healing potential of a fracture healed on the right side whereas walking is still painful on the left side. The isotopic examination was negative, in contradiction to the radiological survey, and the nail was removed and the presence of a pseudoarthrosis confirmed. Permanent healing occurred three months after reaming and the setting of a longer nail than the first one. In one case, when the isotopic osteomedullography was negative, healing of the fracture occurred six months after the setting of external fixation with permanent compression.
DISCUSSION

In the presence of a simple closed fracture, or of an open comminuted fracture which does not heal within the usual time, the orthopaedic surgeon must be able to distinguish between a simple delay in
INJECTION

1. Positive case (A) the tracer goes through the fracture; (B) radiological aspect of pseudoarthrosis eight months after the fracture; (c) sometime later the healing is effective.
FIG.

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

FRACTURE

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

INJECTION"

c 2. Negative case, (A) the tracer stagnates in the lower metaphysis; (B) nailing fracture. A doubt remains about the healing of the fracture; (c) the presence of a pseudoarthrosis is confirmed after the nail is removed.
FIG.

healing and an evolution towards a pseudoarthrosis requiring a bone graft. Many studies have been undertaken with osteotropic radioisotopes to try to solve this problem. Most of them have been unhelpful. In fact, several problems are involved which limit the interest of such investigations. First, the choice of the radionuclide which theoretically should be one of the radioisotopes of calcium or phosphorous. Unfortunately, the physical characteristics of these radionuclides are not really convenient for scintigraphy, and the conclusive phase of skeletal investigation has started only with the use of 85Sr,
866

SEPTEMBER 1980

New radioisotopic method for evaluation of the healing potential of a fracture

TABLE IV
ANALYSIS OF NEGATIVE CASES

Injury

Treatment Nailing External fixation External fixation Plate Plate External fixation External fixation Plate Plate Plate

Confirmation pseudoarthrosis
Y Y Y N Y Y Y Y Y Y

Complementary treatment Reaming + Nailing Graft Graft Osteotomy cf fibula+ External fixation Cancellous graft External fixation Graft Cancellous graft Graft + External fixation Reaming + Nailing

fP1 O B P3 O B P3OC P2OB-r

Ov\ P2OB + LP2OA fPOOB[PO OA

| P3 O B P3 OC

Sr m , 1 8 F, and now principally with phosphate compounds labelled with " T c m , particularly 99Tcmpyrophosphate. Whereas the general utility of the latter is beyond doubt, its use for studies in reparative osteogenesis has been subject to some reservation, for it seems that calcium accretion at the level of the fracture focus does not correspond with it. The second difficulty encountered concerns the prognostic value of the ratio between the activities in the fractured and in the normal bone. A slight fixation of the radioactive product at the level of the fracture indicates indeed a deficient formation of callus, but in some pseudoarthroses the activity ratio is normal or even high (vascular pseudoarthrosis). Moreover, it is difficult to distinguish the fixation of the tracer at the level of the bone callus from the fixation due to some inflammatory process. Repeated scintigraphic examinations between the 3rd and the 30th week following the accident may be of some interest, but will delay the answer for the orthopaedic surgeon. Analysis of the 23 fracture cases explored by isotopic osteomedullography shows that resumption of centromedullary circulation of the bone is necessary for healing of a fracture. Among the 12 positive examinations, not a single false result has been observed. In all cases, the evolution of the focus has appeared to be spontaneously favourable. Thus, any surgical treatment of a pseudoarthrosis which would not clear the medullary canals would be inefficient. Such was the case with a 31-year-old patient with an open fracture of the left leg which had required the setting of a plate. Eight months later a bone graft was made, associated with external fixation. This intervention proved to be a failure. Eighteen months

87

later, in view of the hypervascular radiological aspect of the pseudoarthrosis, it was decided to perform an osteotomy of the fibula in spite of negative isotopic osteomedullography with permanent compression of the fracture focus by external fixation. Four months later, as healing was still not obtained, an intertibiofibular graft was carried out successfully. However, in order to obtain healing of fractures, it is possible either to optimize the periosteal circulation (just with compression plating on the outside of the bone or by Judet's decortication method) or to improve the medullary circulation with a new reaming. The choice is given to the surgeon but we think that non-resumption of medullary circulation explains repeated fractures, for example after a Papineau operation. Among the negative examinations, nine were in connection with an existing pseudoarthrosis. In one case, the result of the radioisotopic examination was rather disturbing: a 23-year-old man with a B + type open fracture of the right leg was treated with external fixation. Seven months later a pseudoarthrosis had developed at the level of the fracture and isotopic osteomedullography was negative. An osteotomy of the fibula was then carried out associated with permanent compression of the fracture focus by external fixation, and six months later the fracture healed. A further isotopic examination was still negative. Thus, it seems that the study of the centromedullary circulation of the bone is not the only factor to be considered in evaluating the healing of a fracture focus.
REFERENCES BAUER, G., 1968. The use of radionuclides in orthopaedicsradio-nuclide scintimetry of the skeleton. Journal of Bone and Joint Surgery, 50-A, 1681 -1709.

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of osteomedullography in fractures of the tibial shaft, Journal of Bone and Joint Surgery, 56-A, 759-776. RHINELANDER, F. W., 1968. The normal microcirculation of diaphyseal cortex and its response to fracture, Journal of Bone and Joint Surgery, 50-A, 784-800.

JOHANSEN, A., 1973. Fracture healing controlled by 87m Sr uptake. Ada orthopaedica scandinavica, 44, 628-639. MUHEIM, G.,87m 1973. Assessment of fracture healing in man by serial strontium-scintimetry. Ada orthopaedica Scandinavica, 44, 621 -627.
PURANEN, J., and KASKI, P., 1974. The clinical significance

Book review
Einfiihrung in die Rontgendiagnostik. By Peter Thurn and Egon Bucheler, pp.ix+523, 1979 (German Text), (Thieme, Stuttgart), DM.84. ISBN 3-13-3160-060 The fact that this is already the 6th edition since 1959 would indicate that this "Introduction to Radiological Diagnosis" is very popular in the German-speaking world. The reasons for this are quite clear. The book is a very handy "quarto" format, beautifully produced with many excellent reproductions that even reproduce miliary tuberculosis and silicosis. Ultrasound and computerized tomography are included in the relevant sections. There are chapters on the physical basis of the techniques used, radiology of the skeletal system, thorax, abdominal organs, obstetrics and gynaecology, and soft tissues. There are very good tables indicating the radiation dose to the gonads 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 make strange reading and are hopefully incorrecta Dutch barium swallow delivers 50 mrad to the bone marrow while an Englishman gets a whacking 1300. Similar differences exist for other examinations. These are very thoughtprovoking statistics. There are a few errors. Fig. 150, p. 141, supposedly illustrating a Klippel Feil deformity of the neck, is a radiograph of the dorsal spine. Fig. 549, p.448, is a much reproduced set of diagrams illustrating congenital renal abnormalities in which the terminations of duplex ureters are incorrectly placed. A more serious criticism is the lack of paediatric information. There are no illustrations of RDS, lobar emphysema, urethral valves, ureterocele in childhood, the importance of malrotation of the midgut, neonatal Hirschsprung's diseaseall matters of vital importance. Neuroradiology is not discussed at all. The book fulfils its purpose as an introduction to radiology very well. It is up to date, clearly written and beautifully illustrated, and small enough to fit easily into a briefcase.
G. M. STEINER.