Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2021 Dec 7;56(6):796-803.
doi: 10.1055/s-0041-1724072. eCollection 2021 Dec.

Monitoring the Progress of Treatment in Fracture Non-Union: The Role of Alkaline Phosphatase and Ultrasonography

Dhanji S Chaudhary  1 , Jayur J Solanki  1 , Tarun Verma  1 , Viswanath H Chavali  1
Affiliations

Monitoring the Progress of Treatment in Fracture Non-Union: The Role of Alkaline Phosphatase and Ultrasonography

Dhanji S Chaudhary et al. Rev Bras Ortop (Sao Paulo). .

Abstract

Objective To evaluate the role of serum alkaline phosphatase (ALP) and ultrasonography (USG) in monitoring the progress of treatment in diaphyseal non-unions. Methods This prospective observational cohort study included adult patients with diaphyseal fractures of major long bones previously treated with internal fixation and eventually resulting in non-union. Following the definitive treatment for non-union, the patients were followed-up periodically for six months, and serial monitoring of the levels of ALP and USG were performed along with radiographs (X-rays) to ascertain the status of the union. Results After an initial rise at seven weeks, ALP levels declined to normal values in fractures which united, whereas they remained high in cases of persistent non-union. Similarly, after an elevation of the vascular resistive index (RI) at around 12 weeks in all the patients, it decreased in cases progressing to union, while it remained persistently high even at 24 weeks in fractures failing to unite. Cases of persistent non-union continued to show hypoechogenic callus at 24 weeks instead of converting into hyperechogenic callus, as observed in cases which progressed to union. Conclusion Significant changes suggestive of union appeared simultaneously on the X-rays, USG and ALP levels during the follow-up. However, a serial examination of the ALP levels and USG during the follow-up gave a hint of the direction of progress in the healing process of fracture non-union. Their role in monitoring the outcome of non-union is more complimentary than supplementary to the X-rays.

Keywords: alkaline phosphatase; bony callus; ultrasonography.

PubMed Disclaimer

Conflict of interest statement

Conflito de Interesses Os autores declaram não haver conflito de interesses.

Figures

Fig. 1
Fig. 1
Flowchart showing the basic methodology applied to the present study.
Fig. 2
Fig. 2
Illustrative Case1. ( A ) X-ray showing non-union of the distal tibia; ( B ) ultrasonography (USG) showing fracture gap with high resistive index; ( C ) fracture union after bone grafting at 24 weeks; and ( D ) USG at 24 weeks showing hyperechoic signals and absent vascular resistance.
Fig. 3
Fig. 3
Illustrative Case2. ( A ) X-ray showing non-union of the proximal tibia; ( B ) USG showing heterogenous hypoechoic signals of non-union; ( C ) fracture union after bone grafting at 18 weeks; and ( D ) USG at 18 weeks showing hyperechoic signals.
Fig. 4
Fig. 4
Illustrative Case3. ( A ) X-ray showing non-union shaft of the humerus; ( B ) USG showing fracture gap with high resistive index; ( C ) persistent fracture non-union after 24 weeks of the revision surgery; and ( D ) USG at 24 weeks showing fracture gap, hypoechoic signals and high vascular resistance.
Fig. 5
Fig. 5
Trend of average serum alkaline phosphatase levels in cases of union and non-union.
Fig. 6
Fig. 6
Trend of average vascular resistive index in cases of union and non-union.
Fig. 7
Fig. 7
Vascular changes and their effect on the resistive index in cases of union and non-union.
Fig. 1
Fig. 1
Fluxograma da metodologia básica.
Fig. 2
Fig. 2
Caso ilustrativo 1. ( A ) A radiografia mostra a ausência de consolidação da tíbia distal. ( B ) A ultrassonografia mostra o defeito ósseo com alto índice de resistência. ( C ) Consolidação da fratura 24 semanas após o enxerto ósseo. ( D ) A ultrassonografia em 24 semanas mostra sinais hiperecoicos e ausência de resistência vascular.
Fig. 3
Fig. 3
Caso ilustrativo 2. ( A ) A radiografia mostra a ausência de consolidação da tíbia proximal. ( B ) A ultrassonografia mostra sinais hipoecoicos heterogêneos de ausência de consolidação. ( C ) Consolidação da fratura 18 semanas após o enxerto ósseo. ( D ) A ultrassonografia em 18 semanas mostra sinais hiperecoicos.
Fig. 4
Fig. 4
Caso ilustrativo 3. ( A ) A radiografia mostra a diáfise umeral não consolidada. ( B ) A ultrassonografia mostra o defeito ósseo com alto índice de resistência. ( C ) Ausência de consolidação da fratura 24 semanas após a cirurgia de revisão. ( D ) A ultrassonografia em 24 semanas mostra o defeito ósseo, os sinais hipoecoicos, e a alta resistência vascular.
Fig. 5
Fig. 5
Tendência da concentração sérica média de fosfatase alcalina (FA) na presença ou ausência de consolidação.
Fig. 6
Fig. 6
Tendência do índice de resistência vascular médio na presença ou ausência de consolidação.
Fig. 7
Fig. 7
Alterações vasculares e seus efeitos no índice de resistência vascular (IR) na presença ou ausência de consolidação.
See this image and copyright information in PMC

References

    1. Nandra R, Grover L, Porter K. Fracture non-union epidemiology and treatment. Trauma. 2016;18(01):3–11.
    1. Wawrzyk M, Sokal J, Andrzejewska E, Przewratil P. The role of ultrasound imaging of callus formation in the treatment of long bone fractures in children. Pol J Radiol. 2015;80:473–478. - PMC - PubMed
    1. Zimmermann G, Müller U, Wentzensen A.The value of laboratory and imaging studies in the evaluation of long-bone non-unions[published correction appears in Injury. 2007;38(10):1224]Injury 20073802S33–S37. - PubMed
    1. Taniguchi T, Matsumoto T, Shindo H. Changes of serum levels of osteocalcin, alkaline phosphatase, IGF-I and IGF-binding protein-3 during fracture healing. Injury. 2003;34(07):477–479. - PubMed
    1. Ajai S, Sabir A, Mahdi A A, Srivastava R N. Evaluation of serum alkaline phosphatase as a biomarker of healing process progression of simple diaphyseal fractures in adult patients. Int Res J Biol Sci. 2013;2:40–43.