Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
European Radiology
Published in: European Radiology 2/2014

01-02-2014 | Musculoskeletal

Dynamic contrast-enhanced magnetic resonance imaging can assess vascularity within fracture non-unions and predicts good outcome

Authors: Oliver Schoierer, Konstantin Bloess, Daniel Bender, Iris Burkholder, Hans-Ulrich Kauczor, Gerhard Schmidmaier, Marc-André Weber

Published in: European Radiology | Issue 2/2014

Login to get access

Abstract

Objectives

To prospectively evaluate whether dynamic contrast-enhanced (DCE) MRI can assess vascularity within non-unions and predicts clinical outcome in combination with the clinical Non-Union Scoring System (NUSS).

Methods

Fifty-eight patients with non-unions of extremities on CT underwent 3-T DCE MRI. Signal intensity curves obtained from a region-of-interest analysis were subdivided into those with more intense contrast agent uptake within the non-union than in adjacent muscle (vascularised non-union) and those with similar or less contrast uptake. The pharmacokinetic parameters of the Tofts model K trans, K ep, iAUC and V e were correlated with union at CT 1 year later (n = 49).

Results

Despite inserted osteosynthetic material, DCE parameters could be evaluated in 57 fractures. The sensitivity/specificity of vascularised non-unions as an indicator of good outcome was 83.9 %/50.0 % compared to 96.8 %/33.3 % using NUSS (n = 49). Logistic regression revealed a significant impact of NUSS on outcome (P = 0.04, odds ratio = 0.93). At first examination, median iAUC (initial area under the enhancement curve) for the ratio non-union/muscle was 10.28 in patients with good outcome compared with 3.77 in non-responders (P = 0.023). K trans, K ep and Ve within the non-union were not significantly different initially (n = 57) or 1 year later (n = 19).

Conclusions

DCE MRI can assess vascularity in fracture non-unions. A vascularised non-union correlates with good outcome.

Key points

• Dynamic contrast-enhanced magnetic resonance imaging can assess vascularity within bony non-unions.
• Vascularised ununited fractures appear better at 1-year CT than poorly vascularised fractures.
• Non-union healing after osteosynthesis or osteoinductive drugs fundamentally requires vascularity.
• DCE MRI predicts treatment outcome better than the clinical Non-Union Scoring System.
• DCE MRI is clinically feasible to predict treatment outcome in bony non-unions.
Literature
1.
2.
Cruess RL, Dumont J (1975) Fracture healing. Can J Surg 18:403–413PubMed
3.
Frost HM (1989) The biology of fracture healing. An overview for clinicians. Part II. Clin Orthop Relat Res 248:294–309PubMed
4.
Hendrex RW (1992) Fracture healing. In: Rogers LF (ed) Radiology of skeletal trauma, 2nd edn. Churchill Livingstone, New York, pp 203–221
5.
Marsh D (1998) Concepts of fracture union, delayed union, and nonunion. Clin Orthop Relat Res 355:S22–S30PubMedCrossRef
6.
Kuhlman JE, Fishman EK, Magid D, Scott WW Jr, Brooker AF, Siegelman SS (1988) Fracture nonunion: CT assessment with multiplanar reconstruction. Radiology 167:483–488PubMed
7.
Bhattacharyya T, Bouchard KA, Phadke A, Meigs JB, Kassarjian A, Salamipour H (2006) The accuracy of computed tomography for the diagnosis of tibial nonunion. J Bone Joint Surg Am 88:692–697PubMedCrossRef
8.
Calori GM, Mazza E, Colombo M, Ripamonti C, Tagliabue L (2011) Treatment of long bone non-unions with polytherapy: indications and clinical results. Injury 42:587–590PubMedCrossRef
9.
Calori GM, Tagliabue L, Gala L, d’Imporzano M, Peretti G, Albisetti W (2008) Application of rhBMP-7 and platelet-rich plasma in the treatment of long bone non-unions: a prospective randomised clinical study on 120 patients. Injury 39:1391–1402PubMedCrossRef
10.
Friedlaender GE, Perry CR, Cole JD et al (2001) Osteogenic protein-1 (bone morphogenetic protein-7) in the treatment of tibial nonunions. J Bone Joint Surg Am 83-A:S151–S158PubMed
11.
Garrison KR, Shemilt I, Donell S et al (2010) Bone morphogenetic protein (BMP) for fracture healing in adults. Cochrane Database Syst Rev 6, CD006950PubMed
12.
Geesink RG, Hoefnagels NH, Bulstra SK (1999) Osteogenic activity of OP-1 bone morphogenetic protein (BMP-7) in a human fibular defect. J Bone Joint Surg Br 81:710–718PubMedCrossRef
13.
Giannoudis PV, Einhorn TA, Schmidmaier G, Marsh D (2008) The diamond concept-open questions. Injury 39:S5–S8PubMedCrossRef
14.
Govender S, Csimma C, Genant HK et al (2002) Recombinant human bone morphogenetic protein-2 for treatment of open tibial fractures: a prospective, controlled, randomized study of four hundred and fifty patients. J Bone Joint Surg Am 84-A:2123–2134PubMed
15.
Schmidmaier G, Schwabe P, Wildemann B, Haas NP (2007) Use of bone morphogenetic proteins for treatment of non-unions and future perspectives. Injury 38:S35–S41PubMedCrossRef
16.
Schmidmaier G, Capanna R, Wildemann B, Beque T, Lowenberg D (2009) Bone morphogenetic proteins in critical-size bone defects: what are the options? Injury 40:S39–S43PubMedCrossRef
17.
Giannoudis PV, Einhorn TA, Marsh D (2007) Fracture healing: the diamond concept. Injury 38:S3–S6CrossRef
18.
19.
Calori GM, Phillips M, Jeetle S, Tagliabue L, Giannoudis PV (2008) Classification of non-union: need for a new scoring system? Injury 39:S59–S63PubMedCrossRef
20.
Weber BG, Cech O (1976) Pseudoarthrosis: Pathology, biomechanics, therapy, results. Hans Huber, Bern
21.
Calori GM, Giannoudis PV (2011) Enhancement of fracture healing with the diamond concept: the role of the biological chamber. Injury 42:1191–1193PubMedCrossRef
22.
Choyke PL, Dwyer AJ, Knopp MV (2003) Functional tumor imaging with dynamic contrast-enhanced magnetic resonance imaging. J Magn Reson Imaging 17:509–520PubMedCrossRef
23.
Hawighorst H, Libicher M, Knopp MV, Moehler T, Kauffmann GW, Kaick G (1999) Evaluation of angiogenesis and perfusion of bone marrow lesions: role of semiquantitative and quantitative dynamic MRI. J Magn Reson Imaging 10:286–294PubMedCrossRef
24.
Libicher M, Bernd L, Schenk JP, Madler U, Grenacher L, Kauffmann GW (2001) Characteristic perfusion pattern of osseous giant cell tumor in dynamic contrast-enhanced MRI. Radiologe 41:577–582PubMedCrossRef
25.
Libicher M, Kasperk C, Daniels M, Hosch W, Kauczor HU, Delorme S (2008) Dynamic contrast-enhanced MRI in Paget's disease of bone—correlation of regional microcirculation and bone turnover. Eur Radiol 18:1005–1011PubMedCrossRef
26.
Munk PL, Lee MJ, Janzen DL et al (1998) Gadolinium-enhanced dynamic MRI of the fractured carpal scaphoid: preliminary results. Australas Radiol 42:10–15PubMedCrossRef
27.
Hirata T, Konishiike T, Kawai A, Sato T, Inoue H (2001) Dynamic magnetic resonance imaging of femoral head perfusion in femoral neck fracture. Clin Orthop Relat Res 393:294–301PubMedCrossRef
28.
Griffith JF, Yeung DK, Tsang PH et al (2008) Compromised bone marrow perfusion in osteoporosis. J Bone Miner Res 23:1068–1075PubMedCrossRef
29.
Yeung DK, Lam SL, Griffith JF et al (2008) Analysis of bone marrow fatty acid composition using high-resolution proton NMR spectroscopy. Chem Phys Lipids 151:103–109PubMedCrossRef
30.
31.
Ehrhart N, Kraft S, Conover D, Rosier RN, Schwarz EM (2008) Quantification of massive allograft healing with dynamic contrast enhanced-MRI and cone beam-CT: a pilot study. Clin Orthop Relat Res 466:1897–1904PubMedCrossRef
32.
Klaue K, Knothe U, Anton C et al (2009) Bone regeneration in long-bone defects: tissue compartmentalisation? In vivo study on bone defects in sheep. Injury 40:S95–S102PubMedCrossRef
33.
Masquelet AC, Begue T (2010) The concept of induced membrane for reconstruction of long bone defects. Orthop Clin North Am 41:27–37PubMedCrossRef
34.
Pelissier P, Martin D, Baudet J, Lepreux S, Masquelet AC (2002) Behaviour of cancellous bone graft placed in induced membranes. Br J Plast Surg 55:596–598PubMedCrossRef
35.
Pelissier P, Masquelet AC, Bareille R, Pelissier SM, Amedee J (2004) Induced membranes secrete growth factors including vascular and osteoinductive factors and could stimulate bone regeneration. J Orthop Res 22:73–79PubMedCrossRef
36.
Savolaine ER, Ebraheim N (2000) Assessment of femoral neck nonunion with multiplanar computed tomography reconstruction. Orthopedics 23:713–715PubMed
37.
Slade JF 3rd, Gillon T (2008) Retrospective review of 234 scaphoid fractures and nonunions treated with arthroscopy for union and complications. Scand J Surg 97:280–289PubMed
38.
Taylor JS, Tofts PS, Port R et al (1999) MR imaging of tumor microcirculation: promise for the new millennium. J Magn Reson Imaging 10:903–907PubMedCrossRef
39.
Tofts PS, Brix G, Buckley DL et al (1999) Estimating kinetic parameters from dynamic contrast-enhanced T(1)-weighted MRI of a diffusable tracer: standardized quantities and symbols. J Magn Reson Imaging 10:223–232PubMedCrossRef
40.
Tofts PS, Kermode AG (1991) Measurement of the blood-brain barrier permeability and leakage space using dynamic MR imaging. 1. Fundamental concepts. Magn Reson Med 17:357–367PubMedCrossRef
41.
Keramaris NC, Calori GM, Nikolaou VS et al (2008) Fracture vascularity and bone healing: a systematic review of the role of VEGF. Injury 39:S45–S57PubMedCrossRef
42.
43.
Giannoudis PV, Tzioupis C (2005) Clinical applications of BMP-7: the UK perspective. Injury 36:S47–S50PubMedCrossRef
44.
Weber MA, Krix M, Delorme S (2007) Quantitative evaluation of muscle perfusion with CEUS and with MR. Eur Radiol 17:2663–2674PubMedCrossRef
45.
Slotboom J, Schaer R, Ozdoba C et al (2008) A novel method for analyzing DSCE-images with an application to tumor grading. Invest Radiol 43:843–853PubMedCrossRef
46.
Wetzel SG et al (2002) Relative cerebral blood volume measurements in intracranial mass lesions: interobserver and intraobserver reproducibility study. Radiology 224:797–803PubMedCrossRef
47.
Nosàs-Garcia S, Moehler T, Wasser K et al (2005) Dynamic contrast-enhanced MRI for assessing the disease activity of multiple myeloma: a comparative study with histology and clinical markers. J Magn Reson Imaging 22:154–162PubMedCrossRef
48.
Shapeero LG, Poffyn B, De Visschere PJ et al (2011) Complications of bone tumors after multimodal therapy. Eur J Radiol 77:51–67PubMedCrossRef
49.
Jans L, De Coninck T, Wittoek R et al (2013) 3 T DCE-MRI assessment of synovitis of the interphalangeal joints in patients with erosive osteoarthritis for treatment response monitoring. Skeletal Radiol 42:255–260PubMedCrossRef
50.
Krix M, Weber MA, Krakowski-Roosen H et al (2005) Assessment of skeletal muscle perfusion using contrast-enhanced ultrasonography. J Ultrasound Med 24:431–441PubMed
51.
Weber MA, Krakowski-Roosen H, Delorme S et al (2006) Relationship of skeletal muscle perfusion measured by contrast-enhanced ultrasonography to histologic microvascular density. J Ultrasound Med 25:583–591PubMed
52.
Lang P, Honda G, Roberts T et al (1995) Musculoskeletal neoplasm: perineoplastic edema versus tumor on dynamic postcontrast MR images with spatial mapping of instantaneous enhancement rates. Radiology 197:831–839PubMed
53.
Verstraete KL, Lang P (2000) Bone and soft tissue tumors: the role of contrast agents for MR imaging. Eur J Radiol 34:229–246PubMedCrossRef
Metadata
Title
Dynamic contrast-enhanced magnetic resonance imaging can assess vascularity within fracture non-unions and predicts good outcome
Authors
Oliver Schoierer
Konstantin Bloess
Daniel Bender
Iris Burkholder
Hans-Ulrich Kauczor
Gerhard Schmidmaier
Marc-André Weber
Publication date
01-02-2014
Publisher
Springer Berlin Heidelberg
Published in
European Radiology / Issue 2/2014
Print ISSN: 0938-7994
Electronic ISSN: 1432-1084
DOI
https://doi.org/10.1007/s00330-013-3043-3

Other articles of this Issue 2/2014

European Radiology 2/2014 Go to the issue

Gastrointestinal

Diffusion-weighted imaging with acquisition of three b-values for response evaluation of neuroendocrine liver metastases undergoing selective internal radiotherapy

Oncology

Performance of gadofosveset-enhanced MRI for staging rectal cancer nodes: can the initial promising results be reproduced?

Emergency Radiology

Clinical impact of hyperattenuation of adrenal glands on contrast-enhanced computed tomography of polytraumatised patients

Computed Tomography

Low-tube-voltage (80 kVp) CT aortography using 320-row volume CT with adaptive iterative reconstruction: lower contrast medium and radiation dose

Musculoskeletal

Prevalence and risk factors of lumbar spondylolisthesis in elderly Chinese men and women

Cardiac

Automated Quantification of Epicardial Adipose Tissue Using CT Angiography: Evaluation of a Prototype Software