[Partial femur head necrosis in adults--results with intertrochanteric osteotomy and revascularization]

Osteotomy and revascularization have both been used for many years in the therapy of partial aseptic necrosis of the femoral head in the adult. We first attempted a combination of the two techniques in 1978. Stress on the necrotic sector was relieved by intertrochanteric osteotomy, and the necrotic part of the bone was revascularized with a pedicled iliac crest bone graft based on the deep circumflex iliac vessels. Long-term results are now available in 45 hips in 38 patients, with a mean follow-up time of 32 months. Clinically, 71% of the hips were rated very good or good, and among those classed as stage II before surgery the results were rated as very good or good in as many as 90%. Subjective evaluation of the hips by the patients confirmed these results: 85% of the hips were judged to be optimal or markedly improved compared with before operation. Radiological evaluation showed further flattening of the femoral head in one case. A segmental collapse of the femoral head, i.e. stage III lesion according to Ficat, occurred in 2 hips with stage II preoperatively. In 6 hips with stage III necrosis preoperatively secondary arthritis developed. Computerized tomograms taken of all 25 hips from which metal implants had been removed showed signs of integration of the graft in 68%. Scintigraphy with 99-Tc-diphosphonate showed a homogeneous uptake in 42.8% and a non-homogeneous uptake in the remaining 57.2% of the cases. So-called photopenia was not observed in any of the hip joints treated.(ABSTRACT TRUNCATED AT 250 WORDS)

Intramedullary nails for pediatric diaphyseal femur fractures in older, heavier children: early results

PURPOSE A common treatment for pediatric femur fractures is intramedullary nail (IMN) insertion. Elastic stable intramedullary nails (ESINs) are often used for these procedures in heavier patients, but the potential for complications and malunion is greater. We describe here a rigid IMN specifically designed for adolescents, the adolescent lateral entry femoral nail (ALFN). The purpose of this study was to compare the recovery and complications for patients treated with ESINs to those treated with the ALFN. METHODS Our study design was a retrospective cohort study. We performed a review of medical records of 22 children ages 10-17 requiring surgical fixation of a femur fracture for a 2½-year period. Patients selected for the study had traumatic diaphyseal femur fractures and were treated with ESINs without end-caps or ALFNs. Our analyses evaluated injury, surgical, and outcome information for all patients. RESULTS Twenty-two patients were eligible for inclusion and were divided into two groups according to their treatment: the ESIN group with 7 patients and the ALFN group with 15 patients. We then performed a comparison of complications and recovery for these patients. The mean time to full weight-bearing was significantly less for the ALFN group (4.1 weeks; SD, 2.2), than the ESIN group (9.4 weeks; SD 3.9). There was no statistical difference in the incidence of major or minor complications. CONCLUSIONS Older, heavier pediatric patients treated for femur fracture with ALFNs had a shorter recovery time than similar patients treated with ESINs. However, the outcomes for both groups were satisfactory.

A nonlinear QCT-based finite element model validation study for the human femur tested in two configurations in vitro

Purpose Femoral fracture is a common medical problem in osteoporotic individuals. Bone mineral density (BMD) is the gold standard measure to evaluate fracture risk in vivo. Quantitative computed tomography (QCT)-based homogenized voxel finite element (hvFE) models have been proved to be more accurate predictors of femoral strength than BMD by adding geometrical and material properties. The aim of this study was to evaluate the ability of hvFE models in predicting femoral stiffness, strength and failure location for a large number of pairs of human femora tested in two different loading scenarios. Methods Thirty-six pairs of femora were scanned with QCT and total proximal BMD and BMC were evaluated. For each pair, one femur was positioned in one-legged stance configuration (STANCE) and the other in a sideways configuration (SIDE). Nonlinear hvFE models were generated from QCT images by reproducing the same loading configurations imposed in the experiments. For experiments and models, the structural properties (stiffness and ultimate load), the failure location and the motion of the femoral head were computed and compared. Results In both configurations, hvFE models predicted both stiffness (R2=0.82 for STANCE and R2=0.74 for SIDE) and femoral ultimate load (R2=0.80 for STANCE and R2=0.85 for SIDE) better than BMD and BMC. Moreover, the models predicted qualitatively well the failure location (66% of cases) and the motion of the femoral head. Conclusions The subject specific QCT-based nonlinear hvFE model cannot only predict femoral apparent mechanical properties better than densitometric measures, but can additionally provide useful qualitative information about failure location.

Statistical model-based segmentation of the proximal femur in digital antero-posterior (AP) pelvic radiographs.

PURPOSE    Segmentation of the proximal femur in digital antero-posterior (AP) pelvic radiographs is required to create a three-dimensional model of the hip joint for use in planning and treatment. However, manually extracting the femoral contour is tedious and prone to subjective bias, while automatic segmentation must accommodate poor image quality, anatomical structure overlap, and femur deformity. A new method was developed for femur segmentation in AP pelvic radiographs. METHODS    Using manual annotations on 100 AP pelvic radiographs, a statistical shape model (SSM) and a statistical appearance model (SAM) of the femur contour were constructed. The SSM and SAM were used to segment new AP pelvic radiographs with a three-stage approach. At initialization, the mean SSM model is coarsely registered to the femur in the AP radiograph through a scaled rigid registration. Mahalanobis distance defined on the SAM is employed as the search criteria for each annotated suggested landmark location. Dynamic programming was used to eliminate ambiguities. After all landmarks are assigned, a regularized non-rigid registration method deforms the current mean shape of SSM to produce a new segmentation of proximal femur. The second and third stages are iteratively executed to convergence. RESULTS    A set of 100 clinical AP pelvic radiographs (not used for training) were evaluated. The mean segmentation error was [Formula: see text], requiring [Formula: see text] s per case when implemented with Matlab. The influence of the initialization on segmentation results was tested by six clinicians, demonstrating no significance difference. CONCLUSIONS    A fast, robust and accurate method for femur segmentation in digital AP pelvic radiographs was developed by combining SSM and SAM with dynamic programming. This method can be extended to segmentation of other bony structures such as the pelvis.

Robust Proximal Femur Segmentation in Conventional X-Ray Images via Random Forest Regression on Multi-resolution Gradient Features

In this paper, we propose a fully automatic, robust approach for segmenting proximal femur in conventional X-ray images. Our method is based on hierarchical landmark detection by random forest regression, where the detection results of 22 global landmarks are used to do the spatial normalization, and the detection results of the 59 local landmarks serve as the image cue for instantiation of a statistical shape model of the proximal femur. To detect landmarks in both levels, we use multi-resolution HoG (Histogram of Oriented Gradients) as features which can achieve better accuracy and robustness. The efficacy of the present method is demonstrated by experiments conducted on 150 clinical x-ray images. It was found that the present method could achieve an average point-to-curve error of 2.0 mm and that the present method was robust to low image contrast, noise and occlusions caused by implants.

Image-based vs. mesh-based statistical appearance models of the human femur: Implications for finite element simulations.

Statistical appearance models have recently been introduced in bone mechanics to investigate bone geometry and mechanical properties in population studies. The establishment of accurate anatomical correspondences is a critical aspect for the construction of reliable models. Depending on the representation of a bone as an image or a mesh, correspondences are detected using image registration or mesh morphing. The objective of this study was to compare image-based and mesh-based statistical appearance models of the femur for finite element (FE) simulations. To this aim, (i) we compared correspondence detection methods on bone surface and in bone volume; (ii) we created an image-based and a mesh-based statistical appearance models from 130 images, which we validated using compactness, representation and generalization, and we analyzed the FE results on 50 recreated bones vs. original bones; (iii) we created 1000 new instances, and we compared the quality of the FE meshes. Results showed that the image-based approach was more accurate in volume correspondence detection and quality of FE meshes, whereas the mesh-based approach was more accurate for surface correspondence detection and model compactness. Based on our results, we recommend the use of image-based statistical appearance models for FE simulations of the femur.

Distal interlocking screw placement in the femur: free-hand versus electromagnetic assisted technique (sureshot).

OBJECTIVES To compare the free-hand (FH) technique of placing interlocking screws to a commercially available electromagnetic (EM) targeting system in terms of operating time, radiation dose, and accuracy of screw placement. METHODS Between September 2011 and July 2012, we prospectively randomized 100 consecutive femur shaft fractures in 99 patients requiring intramedullary nails to either FH using fluoroscopy (n = 43) or EM targeting (n = 38; Sureshot). SETTING Single Level 1 University Hospital Trauma Center. MAIN OUTCOME MEASUREMENTS The 2 groups were assessed for distal locking with respect to time, radiation, and accuracy. RESULTS Eight-one fractures had data accurately recorded (38 EM/43 FH). The average total operative time was 50 minutes (range, 25-88 minutes; SD, 13.9 minutes) for the FH group and 57 minutes (range, 40-103 minutes; SD, 16.12 minutes) for the EM group. The average time for distal locking was 10 minutes (range, 4-16 minutes; SD, 3.56 minutes) with FH and 11 minutes (range, 6-28 minutes; SD, 10.24 minutes) with EM. Average radiation dose for distal locking was significantly less (P < 0.0001) for EM at 230.54 μGy (range, 51-660 μGy; SD, 0.17 μGy) compared with 690.27 μGy (range, 200-2310 μGy; SD, 0.52 μGy) for FH. There were 2 misplaced drill bits in FH and 3 in EM. This was not statistically significant (P = 0.888). CONCLUSIONS The electromagnetic targeting device (Sureshot) significantly reduced radiation exposure during placement of distal interlocking screws, without sacrificing operative time, and was equivalent in accuracy when compared with the FH technique. LEVEL OF EVIDENCE Therapeutic level II.

Development of a balanced experimental–computational approach to understanding the mechanics of proximal femur fractures

The majority of people who sustain hip fractures after a fall to the side would not have been identified using current screening techniques such as areal bone mineral density. Identifying them, however, is essential so that appropriate pharmacological or lifestyle interventions can be implemented. A protocol, demonstrated on a single specimen, is introduced, comprising the following components; in vitro biofidelic drop tower testing of a proximal femur; high-speed image analysis through digital image correlation; detailed accounting of the energy present during the drop tower test; organ level finite element simulations of the drop tower test; micro level finite element simulations of critical volumes of interest in the trabecular bone. Fracture in the femoral specimen initiated in the superior part of the neck. Measured fracture load was 3760 N, compared to 4871 N predicted based on the finite element analysis. Digital image correlation showed compressive surface strains as high as 7.1% prior to fracture. Voxel level results were consistent with high-speed video data and helped identify hidden local structural weaknesses. We found using a drop tower test protocol that a femoral neck fracture can be created with a fall velocity and energy representative of a sideways fall from standing. Additionally, we found that the nested explicit finite element method used allowed us to identify local structural weaknesses associated with femur fracture initiation.

Body Height Estimation from Femur Measurements in Postmortem Computed Tomography

After attending this presentation, attendees will: (1) understand how body height from computed tomography data can be estimated; and, (2) gain knowledge about the accuracy of estimated body height and limitations. The presentation will impact the forensic science community by providing knowledge and competence which will enable attendees to develop formulas for single bones to reconstruct body height using postmortem Computer Tomography (p-CT) data. The estimation of Body Height (BH) is an important component of the identification of corpses and skeletal remains. Stature can be estimated with relative accuracy via the measurement of long bones, such as the femora. Compared to time-consuming maceration procedures, p-CT allows fast and simple measurements of bones. This study undertook four objectives concerning the accuracy of BH estimation via p-CT: (1) accuracy between measurements on native bone and p-CT imaged bone (F1 according to Martin 1914); (2) intra-observer p-CT measurement precision; (3) accuracy between formula-based estimation of the BH and conventional body length measurement during autopsy; and, (4) accuracy of different estimation formulas available.1 In the first step, the accuracy of measurements in the CT compared to those obtained using an osteometric board was evaluated on the basis of eight defleshed femora. Then the femora of 83 female and 144 male corpses of a Swiss population for which p-CTs had been performed, were measured at the Institute of Forensic Medicine in Bern. After two months, 20 individuals were measured again in order to assess the intraobserver error. The mean age of the men was 53±17 years and that of the women was 61±20 years. Additionally, the body length of the corpses was measured conventionally. The mean body length was 176.6±7.2cm for men and 163.6±7.8cm for women. The images that were obtained using a six-slice CT were reconstructed with a slice thickness of 1.25mm. Analysis and measurements of CT images were performed on a multipurpose workstation. As a forensic standard procedure, stature was estimated by means of the regression equations by Penning & Riepert developed on a Southern German population and for comparison, also those referenced by Trotter & Gleser “American White.”2,3 All statistical tests were performed with a statistical software. No significant differences were found between the CT and osteometric board measurements. The double p-CT measurement of 20 individuals resulted in an absolute intra-observer difference of 0.4±0.3mm. For both sexes, the correlation between the body length and the estimated BH using the F1 measurements was highly significant. The correlation coefficient was slightly higher for women. The differences in accuracy of the different formulas were small. While the errors of BH estimation were generally ±4.5–5.0cm, the consideration of age led to an increase in accuracy of a few millimetres to about 1cm. BH estimations according to Penning & Riepert and Trotter & Gleser were slightly more accurate when age-at-death was taken into account.2,3 That way, stature estimations in the group of individuals older than 60 years were improved by about 2.4cm and 3.1cm.2,3 The error of estimation is therefore about a third of the common ±4.7cm error range. Femur measurements in p-CT allow very accurate BH estimations. Estimations according to Penning led to good results that (barely) come closer to the true value than the frequently used formulas by Trotter & Gleser “American White.”2,3 Therefore, the formulas by Penning & Riepert are also validated for this substantial recent Swiss population.

Comparison of proximal femur and vertebral body strength improvements in the FREEDOM trial using an alternative finite element methodology

Denosumab reduced the incidence of new fractures in postmenopausal women with osteoporosis by 68% at the spine and 40% at the hip over 36 months compared with placebo in the FREEDOM study. This efficacy was supported by improvements from baseline in vertebral (18.2%) strength in axial compression and femoral (8.6%) strength in sideways fall configuration at 36 months, estimated in Newtons by an established voxel-based finite element (FE) methodology. Since FE analyses rely on the choice of meshes, material properties, and boundary conditions, the aim of this study was to independently confirm and compare the effects of denosumab on vertebral and femoral strength during the FREEDOM trial using an alternative smooth FE methodology. Unlike the previous FE study, effects on femoral strength in physiological stance configuration were also examined. QCT data for the proximal femur and two lumbar vertebrae were analyzed by smooth FE methodology at baseline, 12, 24, and 36 months for 51 treated (denosumab) and 47 control (placebo) subjects. QCT images were segmented and converted into smooth FE models to compute bone strength. L1 and L2 vertebral bodies were virtually loaded in axial compression and the proximal femora in both fall and stance configurations. Denosumab increased vertebral body strength by 10.8%, 14.0%, and 17.4% from baseline at 12, 24, and 36 months, respectively (p < 0.0001). Denosumab also increased femoral strength in the fall configuration by 4.3%, 5.1%, and 7.2% from baseline at 12, 24, and 36 months, respectively (p < 0.0001). Similar improvements were observed in the stance configuration with increases of 4.2%, 5.2%, and 5.2% from baseline (p ≤ 0.0007). Differences between the increasing strengths with denosumab and the decreasing strengths with placebo were significant starting at 12 months (vertebral and femoral fall) or 24 months (femoral stance). Using an alternative smooth FE methodology, we confirmed the significant improvements in vertebral body and proximal femur strength previously observed with denosumab. Estimated increases in strength with denosumab and decreases with placebo were highly consistent between both FE techniques.

Osteotomy of the distal femur. Surgical technique using the LCP Pediatric Condylar Plate 90°.

OBJECTIVE Correction of all kind of deformities at the distal part of the femur (supracondylar). INDICATIONS Flexion, extension osteotomies, and varus or valgus, and external or internal rotation osteotomies, and shortening osteotomies of the distal femur or combined surgical procedures (e.g., extension and de-rotation osteotomy). CONTRAINDICATIONS Osteotomy through unknown bony process. SURGICAL TECHNIQUE LCP system provides angular stable fixation. POSTOPERATIVE MANAGEMENT Without concomitant surgical procedures of soft tissue (e.g., patellar tendon shortening), early functional rehabilitation is possible with immediate weight bearing (35 kg for small fragment plates and 70 kg for large fragment plates). RESULTS The surgical procedure is safe and is associated with few complications. Overall complication rate in this series of patients was 3%.