FAQ - Bone Healing

What steps do you take after you see an abnormal bone panel before proceeding with surgery?

Assuming we are discussing a nonunion or a delayed union, I would provide a referral to the patient's PCP to correct the abnormalities to allow for the optimal environment for bone healing. With a nonunion, I would also initiate EXOGEN® at this point. There are still times when the situation is so unstable you still need to proceed with surgery even with abnormalities. I take this on a case by case basis.

Answer provided by: Robert Zura, MD

Prior to surgery do you determine if patients are vitamin D deficient?

Not for all patients, but it is becoming more and more common for both acute fractures and nonunions.

Answer provided by: Robert Zura, MD

Do you consider tourniquet time when treating nonunions surgically? Or during primary procedure? Can prolonged acute hypo perfusion cause nonunions?

I am not aware of any literature discussing tourniquet times as it relates to nonunions. I never go over 2 hours on tourniquets.

Answer provided by: Robert Zura, MD

When are you using Vitamin D on your patients?

Whenever levels come back low.

Answer provided by: Robert Zura, MD

Would you recommend supplements for patients while using EXOGEN®?

No, not routinely. I only correct abnormalities if they show on the patient’s panel, and if appropriate, such as vitamin D. If I do not believe they have a good diet, I recommend multi-vitamin.

Answer provided by: Robert Zura, MD

Is there any indication for over the counter calcium to help heal fractures?

Calcium & Vitamin D should be replenished if they are deficient, but I do not routinely use this in fracture healing and am not aware of any literature to support this.

Answer provided by: Robert Zura, MD

Can you provide a simple explanation that you would give to a patient on how EXOGEN® works?

The technology is similar to the type of ultrasound therapy used in physical therapy, fetal scanning or other medical settings. However, the intensity in the wave patterns is different, so there is a different function. As a result of the unique intensity and pattern of the waves that the EXOGEN® unit gives off, it stimulates cells in bone to up regulate proteins to help the cells make bone.

Answer provided by: Robert Zura, MD

Do you think that stopping NSAIDS produce a kind of rebound effect in prostaglandins? If so, can we theoretically use them for one week, stop, wait two weeks and then load again in one week?

There is a temporary effect of non-steroidals on bone healing. I do think it's reversible when stopped. I do not know of any literature regarding prostaglandins.

Answer provided by: Robert Zura, MD

For smokers, does the amount of smoking matter with regards to bone healing?

I do not know of any studies that address the dosing of smoking, but using common sense, I would think it does. Again, I cannot prove this using literature. I do not encourage any smoking during fracture healing.

Answer provided by: Robert Zura, MD

How does long term aspirin affect bone healing? Would you recommend stopping it?

Like non-steroidals, I think aspirin has an effect on pathways, such as COX2. I do not avoid aspirin in bone healing.

Answer provided by: Robert Zura, MD

Is a nicotine patch a reasonable alternative for patients who smoke? Or is that just as detrimental to fracture healing?

Yes, the nicotine patch would still have negative effects on fracture healing. It doesn't have all the other additives but is doesn't eliminate the deleterious effects of smoking. I recommend patients stop smoking.

Answer provided by: Robert Zura, MD

I've heard several definitions of nonunion. Can you clarify the time period scientifically established?

There is no accepted definition. There are many definitions of a nonunion.

Answer provided by: Robert Zura, MD

Do you know if meloxicam has some COX2 inhibition? What about NSAIDs in general?

I would end all NSAIDs in early fracture care. COX2 inhibitors are the most concerning.

Answer provided by: Robert Zura, MD

Is stability a prerequisite for healing?

Yes, in the adult population.

Answer provided by: Robert Zura, MD

Fibroblasts don't form bone, so how does Fibroblast Growth Factor have such a strong effect on fracture healing?

There are 2 different forms of Fibroblast Growth Factor. Fibroblast Growth Factor 1 & Fibroblast Growh Factor 2. Fibroblast Growth Factor 2 is an angiogenic factor and recruits blood vessels. The blood vessels bring with them cells that are progenitors for bone cells. That stimulates the formation of bone.

Answer provided by: Robert Zura, MD

Are there any known oral medications to upregulate cox2?

I am not aware of any oral medications that upregulate COX2.

Answer provided by: Robert Zura, MD


The EXOGEN Ultrasound Bone Healing System is indicated for the non-invasive treatment of established non-unions† excluding skull and vertebra.

In addition, EXOGEN is indicated for accelerating the time to a healed fracture for fresh, closed, posteriorly displaced distal radius fractures and fresh, closed or Grade I open tibial diaphysis fractures in skeletally mature individuals when these fractures are orthopaedically managed by closed reduction and cast immobilization.

There are no known contraindications for the EXOGEN device. Safety and effectiveness has not been established for individuals lacking skeletal maturity; pregnant or nursing women; patients with cardiac pacemakers; on fractures due to bone cancer; or on patients with poor blood circulation or clotting problems. Some patients may be sensitive to the ultrasound gel. Full prescribing information can be found in product labeling, at www.exogen.com or by contacting customer service at 1-800-836-4080.

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Last modified: Thursday, August 6, 2015, 12:38 AM