ultrasonido en fracturas

8/4/2019 Ultrasonido en Fracturas

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INGENIERIA DE REHABILITACIN IngenieraEleclrnica. Automtica y Comunicaciones, Vol. .\.XHI. No. 1.

Acceleration of osseous fracture repairby low-intensity pulsed ultrasound therapy

a preliminary studyO. Rodriguez' & R. M onreaP

'In.s/iiiito de Cibernlica, Matemtica y Fsica (ICIMAf), CITMA , Ciudad de La Habana. Cuba.Hospital Comandante Manuel Fajardo. Ciudad de La Habana, Cuba.

R E SUME N I ABSTRACTUltrasound ti-eatinerit has been show n to stimulate osseous fracture repair in many clinical studies. Tliispaper presen ts the resitlts obtained in a .study effected in a total of fifteen imunited fractures, includingnew fractures, delayed unions an d no-unions were treated dailv for twenty limites with a pulsedultrasound signal of 30 m W/cm- (SATA), and pulse bursts width of 400 s repeated, with a frequency of0,5 kHz. llie treatments were applied until the fractures were clinically and radiographicallv healed.Many of these patients had multiple attempts to achieve union, which failed. Metal fixation was presentin nine of them. Radiograp hie evidence oj healing M'as the bridging by callus of three cortices, andpatients were clinically heated when they could bear weights without pain. None of the treatmentsfailed. In the study it wxis used a Tlierawed 10 IF, an advanced inicroprocessor-controlled apparatus forthe generation of therapeutic ultrasound, designed in comp liance w ith the lEC (InternationalZlect)r/technicaI Commission) Standards.% wonis: iiltrasowul therapy, fnictinv repair, non-nnion.Enmuchos estudios clnicos se ta demostrado que el tratamiento por ultrasonido estimula la reparacin de lasfracuras seas. Este articulo presenta los resultados o btenidos en un total de quince fracturas no unidas .incluyen donueas fracturas, uniones demoradas y no-imiones que fueron tratadas diariamente durante veinte minutos conpiilsis de ultrasonido de 30 m W/cni- (SATA) y pulsos estrechos de 400 s de duracin y una frecuencia de 0.5 kHz.Los ratamientos se mantuvieron hasta que las fracturas, clnica y radiogrficamente, sanaron. Muchos de estospacieites haban intentado curarse sin .\ito. En nueve de ellos haba fijadores metlicos presentes. La e\ idencia decura p r radiografa ie la presencia de puen tes callosos de tres cortezas, y clnicamen te se consideraron curadoscuaiidi pudieron soportar pesos sin dolor. Ninguno de los tratamientos fracas. En este estudio se utiliz elTheramed 101F. un equipo de tecnologa av anzada controlado por m icroprocesador para la generacin de ultrasonidoteraputico que cum ple las no nn as de la IEC (International Electrotechncal Com mission).Pahbrds clave: a~


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Acceleration iil...

NTRODU CTION . :Even though tlie use of tlie ultrasound in medical application

receiv ing an increase d intere st in the researchunity related witli these topics. Tlie best exam ple of tliis isliterature, as well in sessions ofeetings on ultrasonics.Tlie first effect of ultra sou nd in tissue is mechanical vibrations,,and expan sions of tlie medium, witlifrequencyand with amplitude proportional to tie appliedtimulus. This is what is called microm assage or mechan icalherapy. In second place. ie propag ation of the vibrations inhe tissue generates heat for friction. The co mbination of iese

e\'ents, which in turn michains specific biological and ph ysiologicrespond ' It is found, am ong other effects, the follow ingeactions: increase of local sanguine circulation and increase ofabilitN' in tlie cellular m embrmie, reduction of pain , muscu larelaxation, increase of the regeneration of tissues and thexpression of the activity of certain gen es as well the stimu lationo the production of specific enzymes tliat are related \vith healingon tlie mode of the ultrasonic ap plicationor pulsed, it is possible to mmiage tlie increment

One of the most promise application of ultrasound foris for the acceleration of osseous fracture, despite the specific mechan ism by which ultrasound canated fracture healing remain imknowii.HoweA er. different path s of action ha ve been reported , studiesvitro ha\ e indicated responses to low-intensity ultrasound,

ParA izi el o/.** reported in tlie evaluation of the effects of low

ter three and five treatment of 10 min a day.Kokubu et al. ' using an analogous ultrasound signal 20 niin,ion of prostaglandin E2 (PGE2) productionCi T. l -El . The product ion of PGE2 in os teoblas ts was

luiexposed samples. They evaluated theof q cIooxygenase-2 (COX -2) niRNA, which is a criticalor PGE2 production, and found that u ltrasound rap idlyted tlie expression of COX-2 niRNA in a time dq)en dent

They postulated that this results provide a strong evidenceon of COX-2 mRNA expression byulfrasound and offer aistic insight how ultrasound accelerates fracture repairs.

Other studies have reported a modification of calciumincorporation by low-intensity ultrasound in cartilage and bonecell (in vitro), and a vinculum between physical stress andprostag landin E2 in tlie remo deling of bone.'*'Anyway, in 1983 Duarte reported in a model of rabbits, thatlow-intensity pulsed ulfrasound can accelerate the healing of thefracture at tlie site of bilateral osteotomy of fibula and at bilateraldrill holes on the cortex of femur, by radiological ind histologicalevaluations, in a placebo con trolled study.'"Xavier and Duarte demonsfrated acceleration of normal fracturehealing in hum ans nsing this technique. Tliey also iiidiaited thatlow-intensity ultrasound can induce bone repair of ununiteddiaphyseal fractures."Pilla showed in a controlled rabbit model on lnidshaft fibularosteotomies and in prospective double-blind, randomized humanclinical trials in groups of patients suffering Colles's and tibiadiaphyseal fractures, that low-intensity pulsed ultrasoundsignificantly accelerates fresh fracture repair. In addition, hereported that maximal effects occurs at 30 mW/cnr with anultraso und s ignal of 1,5 MH z, 200 ms sine wave burst vvidtli.rqDeatingat 1 kHz.'-Wang eio/.'Reported in highly controlled model of rats onclosed femoral shaft fractures, that low-intensity ulfrasoundstimulation at 0,5 and 1,5 MHz significantly Increased themechiuiical parameters of tlie healing fracture aillu s. when testedto failure in torsion. Moreover, they pointed out that there wasnot a significant difference in ie effects obtained b> these twodifFerent ultrasound frequencies on the mechanical properties oftlie callus.In a multicenter. prospective, randomized, double-blind,placebo-confrolled study, Heckman et al. '" reported a significantacceleration (38 % approximately) of fracture healing in patientswho received active low-intensity pulsed ultrasound for thetreatment of tibia diaphyseal fracture.In tlie same mann er Kristiensen et al. ' 'show n that this type ofultrasound therapy can significantly shortening the time toradiograph ie healing of dorsally angulated fracture of the distalaspect of the radius that had been treated with manipulation andcaster. The tim e to union was significaitly shorter for the fracturetliat were treated with ultrasound tliat it was for those that weretreated w ith placebo 63 3 d comp ared witli 98 5 d.Many otliers clinical investigations VNI tlie use of low-intensitypulsed ultrasound ha\'e been shown sticcessfi.il healing of freshfractures delayed unions aid nonunions, which include fractures,fix ed witli m eta llic implants.'*^" -Taken into account tlie reported results about Uie use of low-intensity pulsed ultrasound in the treatment of bone fractures.and Hie possibility of implementing, for this propose, anequipm entfor clinical investigation at hospital, tlie goals of thisstudy were: l.To use tliis tlierapy for patients affected firstly ofdelayed imion and nonunions. 2. To evaluate by ourselves, theutility of tliis techniqu e.Then, this paper presents tlie results obtained in a studyeffected in the hospital Comandante Manuel Fajardo in Ha\ ma.Cuba, between April 1999 and June 2000 with the use of thistechnique.The equipment used, a Theramed lOlF ulfrasound tlierapygenerator, is an advan ced niicroprocessor-confrolled apparatus,designed in compliance witli the lEC Standards.


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Ingeniera Electrnica, Automtica y Comunicaciones, 1/2002

MA TERIALS AND METHODSThe pr inc ipa l c harac ter i s t ics of the Theram ed 10 IF a rethe following:Ultrasovmd transducer 25 nu n piezoceramic (PZT)

disc with an alum inun frontplate.lM H z .from 30 to 40 mW/cm-, selec-. td in steps of 10 mW/cni^' (SATA)*f rom I to30 iuin.pulsed.400 us cofitainingapproximately 400 sinewavepressure pulses.0.5kHz.

FrequencyUllrasound intensiU-

Treatment timeApplication modePulse burst width

Pulse repetition rates

The re were a total of fifteen patie nts in the study. All of thwere consulted before of the ultrasound applications, obtainia written perm ission. Tlie patients were treated daily for twenminutes with a pulsed u ltrasound sign al of 30 mW /cm' (SATand p ulse bu rsts widtli of 400 m s repeated vvitli a frequency15 kH z. Ultrasound w ater based co upling gel was used betwethe device transducer an d the skin to obtain effective u ltrasoutransmiss ion to tlie fracture.

RESULTSTable 1 presents data from tlie time offractiu"edate, to the st

of ultrasound tlierapy. for each fractured b one. Th e time from tstart of ultrasound therapy to healed fracture, is given in table

Table 3 shows and o va al l sununar>' of fracture locations, atable 4 other procedu res combined with ultrasound therapy.

Table 1 - .Time from fracture date to the start of ultrasound tlierap)'

BoneScaphoidHimiemsTibiaRadiusMeta carpalTotal

Subtotal63312

- . . 15

0-90(d )000022

91-150(d )02010J

151-270( d ) '210003

No-iuiions403007

Table 2Tune for tlie start of ultrasound therapy to healed fractures

BoneScaphoidHiunerus.TibiaRadiusMetacaipalTotaKno M ed )

Subtotal6331215

0-90(d)63I1213

91-150(d)002002-

151-270(d)000000

No- unbns 0

00000


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Accelcratiuii of...

Table 3Overall siinmiirv- by f racture locations

PatieiUs(No)MaleFenialcHealedFaed

Scaphoid

6

6060

Hiunenis

I2

0

3

3030

Radius

1

1010 '

Meta carpal

2

2020

Table 4Otliers proccdiccs combined uitli iil'asoiaid therapy

BonebcaphoidHumeras

libiaEladiiLs

MetacaipalTotalHealed: i5)Fai led (0) ,

Sub-tOtill

6

I2

15

lutenial fix +p epic tiledbone craft

6(J

0(,)0

6

Externallivitiort

0000

0

Externallk +

iittenialli \ +

01010

2

Ititemal fix0

t)1

0-)

Caster021.

0

0

4

DISCUSSIONDespite the current limitation in determining how ultrasound

can induce a healing process for acceleration of bony fracturesthe following considerations may^ be done.

Frequency seems not to be and decisive factor as reported byDuarte'" and Wang et al}^ Nevertlieless, the absorption ofultrasound energy depends on the frequency; and tliis could bean important factor when tlie ultrasor:ic beam has to pass troughdiferent type of tissue, taking into accoimt the coefficients ofabsorption of each one to ultrasoun d. Moreo^ er, this could bean important factor determining tlie deep of penetration of theultrasound in the bone tissue, because of its high absorptioncoefficient.

Thep rocess of fracture repair follows tree overlapping phases;1. Inflammation2. Reparation3. Remodeling.Taking into account the knowledge of tlie interaction of

ultrasound with the tissues it tiiay be postulated that ultrasoundhas its most prominent effects during the first and the secondphases. For example, because the high mismatch between theacoustical impe dance of bone relative to tliat of tlie siuToundingsoft tissues.approximately 25-40 % of ie ultrasound energy isreflected at the bone-tissues interfaces in an intact bone.-'Furtliermore about 80 % of the energy that does penetrate thecortex is adsorbed within the first millimeter of propagation.-*^ Inthe otlier hand, during the inflammatorx' aiid repcirative phases ofrepair, tlie integ rity of tlie outer cortex of bon e is lost, consequentlythis allow a fracture gap or and entr) p oint to ultrasound into theinjured area.

Finally it may be said that Uie variation of temperature in tissuedu e to tlie absorption of energy in tlie rang e used by lovv-iiitensit\pulsed ultrasound (50m W /cnr), is negligible (0,01"C) andinsufficient to generate biological responses.

CONCLUSIONSThe results obtained in the continuation of the realization of

the study, about the use of low-intensit)- pulsed ultrasound inthe treatment of bone fractures, point to confirm the internationalreports as a ^alid and useful therapy for this subject, andencourage us to continue employing this technique to clinicalappliaition.

Th ere were a total of fifteen patie nts in th e study. All of tliemvyere consuhed before of the ultrasound applications, obtaininga written permission. The patients were treated daily for tvyentyminutes with a pulsed ultrasound signal of 3t) mW/cnr(SATA)and pulse bursts \yidth of 400 ms repeated vyitli a frequency of0.5 kHz. Ultrasound water based coupling gel vyas used betweenthe device transduc er and the skin to obtain effective ultrasoundtransmission to the fracture.

REFERENCES1. APTEL,R E.: "Acoustic Cavitation: A Possible Consequenceof Biom dical U se of Ultrasou nd". Br .J Cancer.Vol. 45.pp. 140^6,1982.2. UM EMU RA, S.; K KAWABATA & K. SASAKI:"Enhancement of Sonodynam ic Tissue Damage Productionby Second-Harmonic Superimposition: Tlieoretical Analysisof Its Mechanism". IEE Trans Ultrason f'erroelect Free/Co;?/;: Vol. 43(6), pp. 1054-62, 1996.3. BINDERMA]V,i?ffl/. "TlieTraiisductionofMechiuiicalForceinto Biochemiail Events inBone Cell May Involve Activationof Phosphol ipase A2" . CalcifTissue Internat. Vol. 42.pp. 261-66,1988.


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ii Electi'nk'ii, Autoniiitica > Comunicaciones, I/2U024. REDJSKE, A. IM. et ai: "Ultrasonic Enhancement Action on

Escheiichia Coli Biofilms; an in Vivo Mo del". AntimicrobAgent.'iChenwther.Wo\.43{5lpp. 121 !-4. 1999.

5. NARUSE, K. ef ai "Anabolic Response of Mouse Bone-Manow-Derived Stromal Cell Clone ST2 Cells to Low-intensity Pulsed Ultrasound". Biochetn Biophys ResCom/mm. Vol. 5.286( 1 ), pp. 216-2 0. Februar^'. 2000 .

6. PARVIZI, J.: "Low-Intensity Ultrasound StimulatesProteoglycan S\nthesis in Rat Chond rocytes by Increasing

. Aggrecan Gene Expression". JOrthop Res. 17(4). pp. 488-94..luh. 1999..

7. KOKUBU. T. et ai: -Low Intensity Pulsed UltrasoundExposure Increases Prostaglandin E2 Production Via theInduct ion of Cyc loo . \yge na se - 2 m RN A in MouseOsteoblasts" . Biocheni Biophy.


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ultrasonido en fracturas

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