Does Computed Tomography Change our Observation and Management of Fracture Non-Unions?

Document Type : RESEARCH PAPER


1 Department of Orthopaedic and Trauma Surgery, Joint Research Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands. Division of Orthopaedic Surgery, McMaster University, Canada. Department of Orthopaedic and Trauma Surgery, Deventer ziekenhuis, Deventer, the Netherlands

2 Department of Orthopaedic and Trauma Surgery, Joint Research Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands

3 Division of Orthopaedic Surgery, McMaster University, Canada

4 Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands

5 Department of Orthopaedic and Trauma Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands


Background: The purpose of this study was to determine whether Multi-Detector Computed Tomography (MDCT) in addition to plain radiographs influences radiologists’ and orthopedic surgeons’ diagnosis and treatment plans for
delayed unions and non-unions.
A retrospective database of 32 non-unions was reviewed by 20 observers. On a scale of 1 to 5, observers rated on X-Ray and a subsequent Multi Detector Helical Computer Tomography (MDCT) scan was performed to determine the following categories: "healed", "bridging callus present", "persistent fracture line" or "surgery advised". Interobserver reliability in each category was calculated using the Interclass Correlation Coefficient (ICC). The influence of the MDCT scan on the raters’ observations was determined in each case by subtracting the two scores of both time points.
All four categories show fair interobserver reliability when using plain radiographs. MDCT showed no improvement, the reliability was poor for the categories "bridging callus present" and "persistent fracture line", and fair for "healed" and "surgery advised". In none of the cases, MDCT led to a change of management from nonoperative to operative treatment or vice versa. For 18 out of 32 cases, the treatment plans did not alter. In seven cases MDCT led to operative treatment while on X-ray the treatment plan was undecided.
In this study, the interobserver reliability of MDCT scan is not greater than conventional radiographs for determining non-union. However, a MDCT scan did lead to a more invasive approach in equivocal cases. Therefore a MDCT is only recommended for making treatment strategies in those cases.


Main Subjects

1. Krestan CR, Noske H, Vasilevska V, Weber M, Schueller
G, Imhof H, et al. MDCT versus digital radiography in
the evaluation of bone healing in orthopedic patients.
AJR Am J Roentgenol. 2006; 186(6):1754-60.
2. Kuhlman JE, Fishman EK, Magid D, Scott WW Jr,
Brooker AF, Siegelman SS. Fracture nonunion:
CT assessment with multiplanar reconstruction.
Radiology. 1988; 167(2):483-8.
3. Bhandari M, Guyatt GH, Swiontkowski MF, Tornetta P
3rd, Sprague S, Schemitsch EH. A lack of consensus in
the assessment of fracture healing among orthopaedic
surgeons. J Orthop Trauma. 2002; 16(8):562-6.
4. Sodickson A, Baeyens PF, Andriole KP, Prevedello LM,
Nawfel RD, Hanson R, et al. Recurrent CT, cumulative
radiation exposure, and associated radiation-induced
cancer risks from CT of adults. Radiology. 2009;
5. Brenner DJ, Hall EJ. Computed tomography--an
increasing source of radiation exposure. N Engl J Med.
2007; 357(22):2277-84.
6. Ohashi K, El-Khoury GY, Bennett DL, Restrepo JM,
Berbaum KS. Orthopedic hardware complications
diagnosed with multi-detector row CT. Radiology.
2005; 237(2):570-7.
7. Karanicolas PJ, Bhandari M, Kreder H, Moroni A,
Richardson M, Walter SD, et al. Evaluating agreement:
conducting a reliability study. J Bone Joint Surg Am.
2009; 91(Suppl 3):99-106.
8. Giraudeau B, Mary JY. Planning a reproducibility
study: how many subjects and how many replicates
per subject for an expected width of the 95 per cent
confidence interval of the intraclass correlation
coefficient. Stat Med. 2001; 20(21):3205-14.
9. Cicchetti DV. Guidelines, criteria, and rules of thumb
for evaluating normed and standardized assessment
instruments in psychology. Psychol Assess . 1994;
10. Bhandari M, Chiavaras MM, Parasu N, Choudur H,
Ayeni O, Chakravertty R, et al. Radiographic union score
for hip substantially improves agreement between
surgeons and radiologists. BMC Musculoskelet Disord.
2013; 14(1):1.
11. Whelan DB, Bhandari M, Stephen D, Kreder H, McKee
MD, Zdero R, et al. Development of the radiographic
union score for tibial fractures for the assessment of
tibial fracture healing after intramedullary fixation. J
Trauma. 2010; 68(3):629-32.
12. Buijze GA, Wijffels MM, Guitton TG, Grewal R, van Dijk
CN, Ring D, et al. Interobserver reliability of computed
tomography to diagnose scaphoid waist fracture
union. J Hand Surg Am. 2012; 7(2):250-4.
13. Grewal R, Frakash U, Osman S, McMurtry RY. A
quantitative definition of scaphoid union: determining
the inter-rater reliability of two techniques. J Orthop
Surg Res. 2013; 8(1):28-33.
14. Hannemann PF, Brouwers L, van der Zee D, Stadler
A, Gottgens KW, Weijers R, et al. Multiplanar
reconstruction computed tomography for diagnosis
of scaphoid waist fracture union: a prospective cohort
analysis of accuracy and precision. Skeletal Radiol.
2013; 42(10):1377-82.
15. Bhattacharyya T, Bouchard KA, Phadke A, Meigs JB,
Kassarjian A, Salamipour H. The accuracy of computed
tomography for the diagnosis of tibial nonunion. J
Bone Joint Surg Am. 2006; 88(4):692-7.
16. Koller H, Kolb K, Zenner J, Reynolds J, Dvorak M,
Acosta F, et al. Study on accuracy and interobserver
reliability of the assessment of odontoid fracture
union using plain radiographs or CT scans. Eur Spine
J. 2009; 18(11):1659-68.
Volume 4, Issue 4
October 2016
Pages 337-342
  • Receive Date: 18 April 2016
  • Revise Date: 02 August 2016
  • Accept Date: 07 August 2016
  • First Publish Date: 01 October 2016