Re-evaluation of low intensity pulsed ultrasound in treatment of tibial fractures (TRUST): randomized clinical trial

• Published in: BMJ (Online) 2016-10, Vol.355, p.i5351-i5351
• Main Authors: Busse, Jason W, Bhandari, Mohit, Einhorn, Thomas A, Schemitsch, Emil, Heckman, James D, Tornetta, Paul, Leung, Kwok-Sui, Heels-Ansdell, Diane, Makosso-Kallyth, Sun, Della Rocca, Gregory J, Jones, Clifford B, Guyatt, Gordon H
• Format: Article
• Language: English
• Subjects: Adult; Antibiotics; Bone healing; Bone surgery; Clinical trials; Cortex; Data analysis; Evidence-based medicine; Female; Fracture Fixation, Intramedullary - methods; Fractures; Humans; Male; Medical equipment; Nonunion; Patients; Recovery of function; Regulatory approval; Single-Blind Method; Surgeons; Tibial Fractures - surgery; Tibial Fractures - therapy; Trauma; Treatment Outcome; Ultrasonic imaging; Ultrasonic Therapy - methods; Ultrasonic Waves; Ultrasound
• ISSN: 1756-1833; 0959-8138; 1756-1833
• DOI: 10.1136/bmj.i5351

Objective To determine whether low intensity pulsed ultrasound (LIPUS), compared with sham treatment, accelerates functional recovery and radiographic healing in patients with operatively managed tibial fractures.Design A concealed, randomized, blinded, sham controlled clinical trial with a parallel group design of 501 patients, enrolled between October 2008 and September 2012, and followed for one year.Setting 43 North American academic trauma centers.Participants Skeletally mature men or women with an open or closed tibial fracture amenable to intramedullary nail fixation. Exclusions comprised pilon fractures, tibial shaft fractures that extended into the joint and required reduction, pathological fractures, bilateral tibial fractures, segmental fractures, spiral fractures >7.5 cm in length, concomitant injuries that were likely to impair function for at least as long as the patient’s tibial fracture, and tibial fractures that showed 1 cm gap after surgical fixation. 3105 consecutive patients who underwent intramedullary nailing for tibial fracture were assessed, 599 were eligible and 501 provided informed consent and were enrolled.Interventions Patients were allocated centrally to self administer daily LIPUS (n=250) or use a sham device (n=251) until their tibial fracture showed radiographic healing or until one year after intramedullary fixation.Main outcome measures Primary registry specified outcome was time to radiographic healing within one year of fixation; secondary outcome was rate of non-union. Additional protocol specified outcomes included short form-36 (SF-36) physical component summary (PCS) scores, return to work, return to household activities, return to ≥80% of function before injury, return to leisure activities, time to full weight bearing, scores on the health utilities index (mark 3), and adverse events related to the device.Results SF-36 PCS data were acquired from 481/501 (96%) patients, for whom we had 2303/2886 (80%) observations, and radiographic healing data were acquired from 482/501 (96%) patients, of whom 82 were censored. Results showed no impact on SF-36 PCS scores between LIPUS and control groups (mean difference 0.55, 95% confidence interval −0.75 to 1.84; P=0.41) or for the interaction between time and treatment (P=0.30); minimal important difference is 3-5 points) or in other functional measures. There was also no difference in time to radiographic healing (hazard ratio 1.07, 95% confidence i