Implementation of a novel MRI protocol for diagnosing femoral neck fractures in high energy femoral shaft fractures: One year results

Introduction: Preliminary results using a novel rapid-sequence MRI to diagnose ipsilateral femoral neck fractures in patients sustaining high-energy femoral shaft fractures have been favorable compared to radiographic and CT imaging alone. To evaluate and optimize this new institutional imaging protocol further, we reviewed our results one year after implementation.Methods: Rapid-sequence MRI was added to the imaging evaluation of patients with high-energy femoral shaft fractures without femoral neck fractures identified on radiographs or CT imaging. Data was retrospectively reviewed from a consecutive series of patients who met inclusion criteria.Results: From September 2018 through September 2019, 114 patients sustained 121 high-energy femoral shaft fractures. The average patient age was 29.9 years, 73.7% (84/114) of patients were male, and 16.5% (20/121) were open fractures. Of patients indicated for a rapid-sequence MRI, 86% (92/107) underwent MR imaging. 5% (6/121) of patients had an ipsilateral femoral neck fracture identified on radiographs alone. Three additional femoral neck fractures were identified with CT imaging for an initial incidence of 7.4% (9/121). MRI identified 10 additional non-displaced femoral neck fractures, three complete and seven incomplete fractures, for an incidence of 15.7% (19/121). All identified femoral neck fractures were stabilized.Discussion/Conclusion: The addition of rapid-sequence MRI of the pelvis in patients with high-energy femoral shaft fractures reliably increases the diagnosis of ipsilateral femoral neck fractures not identified with standard imaging. There were no cases of missed/delayed femoral neck fractures in patients with a negative MRI. This new imaging protocol effectively and safely improves the diagnosis of this injury pattern.     

Reverse distal femoral locking compression plate a salvage option in nonunion of proximal femoral fractures

Background:When primary fixation of proximal femoral fractures with implants fails, revision osteosynthesis may be challenging. Tracts of previous implants and remaining insufficient bone stock in the proximal femur pose unique problems for the treatment. Intramedullary implants like proximal femoral nail (PFN) or surface implants like Dynamic Condylar Screw (DCS) are few of the described implants for revision surgery. There is no evidence in the literature to choose one implant over the other. We used the reverse distal femur locking compression plate (LCP) of the contralateral side in such cases undergoing revision surgery. This implant has multiple options of fixation in proximal femur and its curvature along the length matches the anterior bow of the femur. We aimed to evaluate the efficacy of this implant in salvage situations.Results:All fractures exhibited union without any complications. Union was assessed clinically and radiologically. One case of ipsilateral femoral neck and shaft fracture required bone grafting at the second stage for delayed union of the femoral shaft fracture.Conclusions:Reverse distal femoral LCP of the contralateral side can be used as a salvage option for failed fixation of proximal femoral fractures exhibiting nonunion.     

A biomechanical comparison of proximal femoral nails and locking proximal anatomic femoral plates in femoral fracture fixation: A study on synthetic bones

Background:The incidence of fractures in the trochanteric area has risen with the increasing numbers of elderly people with osteoporosis. Although dynamic hip screw fixation is the gold standard for the treatment of stable intertrochanteric femur fractures, treatment of unstable intertrochanteric femur fractures still remains controversial. Intramedullary devices such as Gamma nail or proximal femoral nail and proximal anatomic femur plates are in use for the treatment of intertrochanteric femur fractures. There are still many investigations to find the optimal implant to treat these fractures with minimum complications. For this reason, we aimed to perform a biomechanical comparison of the proximal femoral nail and the locking proximal anatomic femoral plate in the treatment of unstable intertrochanteric fractures.Result:Nail and plate models were locked distally at the same level. Axial steady load with a 5 mm/m velocity was applied through the mechanical axis of femur bone models. Axial loading in the proximal femoral intramedullary nail group was 1.78-fold greater compared to the plate group. All bones that had the plate applied were fractured in the portion containing the distal locking screw.Conclusion:The proximal femoral intramedullary nail provides more stability and allows for earlier weight bearing than the locking plate when used for the treatment of unstable intertrochanteric fractures of the femur. Clinicians should be cautious for early weight bearing with locking plate for unstable intertrochanteric femur fractures.     

Outcome of intramedullary nail for fixation of osteoporotic femoral shaft fractures in the elderly above 60

IntroductionIntramedullary nailing is an acceptable treatment option for femoral shaft fracture in young patients but not extensively studied in the elderly with osteoporotic fractures. Plate fixation for osteoporotic femoral shaft fractures have a high rate of complications and delayed healing time, and the most acceptable treatment is intramedullary nailing. This study evaluated the healing time and incidence of complications in osteoporotic femoral shaft fractures after intramedullary nailing.Patients &MethodsThis was a retrospective study that included 16 patients above 60 years old with osteoporotic femoral shaft fractures operated between January 2015 and December 2018. Patients with metastatic fractures or with atypical fractures were excluded. Thirteen patients had low-energy injuries such as a simple fall from standing height or lower and twisting injuries. The remaining 3 patients sustained high-energy-mechanism of injury. No patient received bisphosphonate except 2 patients received oral bisphosphonate for a period of 6 and 8 months, respectively.ResultsSixteen patients (12 females and 4 males) with mean age 69.5 ± 3.7 presented with femoral shaft fracture were operated with intramedullary nail, 10 patients were fixed with trochanteric entry nails with proximal neck screws, and 6 patients were fixed with piriformis entry nails. In 9 patients, closed reduction of fracture was achieved while 7 patients required open reduction, of which 5 fracture required cerclage wire addition. The mean bone healing time was 5.35±1.2 months. Intraoperative extension of femoral fractures during intramedullary nail insertion was observed in two cases that required open reduction and addition of cerclage wires around the fracture. The overall incidence of complications was 18.7%.ConclusionsIntramedullary nailing for osteoporotic femoral shaft fracture is a good acceptable option in elderly patients with reasonable healing time with no major complications.     

核素骨显像在多发应力性骨折中的应用

目的 本研究通过介绍X线片、CT、MRI、核素骨显像（ECT）在发现应力性骨折中的作用,探讨ECT在多发应力性骨折中的应用。方法 收集自2012-01-2013-06南京军区福州总医院确诊的46例应力性骨折患者的资料,在X线片、CT或MRI检查的基础上加用ECT检查,比较其与其他3种方法的综合效果对应力性骨折的诊断准确性。结果 应力性骨折患者行X线片、CT和MRI检查发现每例患者有1.3个损伤部位,而ECT发现平均1.7个损伤部位。所有患者中48%为多发应力性骨折;ECT检查的患者中56%为多发应力性骨折。结论 军事训练中多发应力性骨折高发;核素骨显像对多发应力性骨折早期诊断和全面诊断具有独特的优势。     

夹板对股骨闭合复位内固定术后碎骨片的复位作用

目的:评估外用夹板对股骨粉碎骨折术后碎骨片的复位作用。方法:自2004年7月-2005年5月收治12例13侧股骨干粉碎骨折,男7例,女5例;平均年龄46.8岁。外伤后1周内施行闭合复位髓内钉内固定术,术中未对骨折处进行剥离固定,术后即刻摄片发现有大块的骨折片明显移位,股骨整体力线和长度恢复良好。予以夹板外固定2⁴周,移位的骨折片处适当加压,每周摄片观察调整。结果:所有病例移位明显的骨折片在夹板固定1周后即有满意的复位,碎骨片向中心轴靠拢0.5³cm,无夹板造成的软组织挤压伤,创口I期甲级愈合,骨折愈合时间平均16.2周,患侧髋、膝关节功能良好。结论:外用夹板对股骨碎骨片的复位疗效确切、方法简便,与微创内固定相互结合,明显提高疗效。     

Fehldiagnose “Knochentumor” bei Stressfraktur am medialen Tibiaplateau

Stress fractures occur in 13.2-37.0% in running athletes. There is a decreasing incidence of these fractures in the tibia (33%), navicular (20%), metatarsus (20%), femur (11%), fibula (7%) and pelvis (7%). Clinically stress fractures present themselves with uncharacteristic local pain under weightbearing conditions. In 75% the medial tibial crest is involved. Usually the pain disappears when the patient is non-weightbearing. As causal factors wrong training methods, oligomenorrhoe (6x incidence), low nutrition input (8x incidence) and a genu recurvatum-morphotype can be found. Misinterpretation can result from a similar clinical and radiological (conventional x-ray, scintigraphy, MRI) early course in stress fractures and bone tumors. We present a patient with a clinical diagnosis of a meniscus lesion. The following MRI was suspect for a malignant lymphoma or histiocytoma. Biopsy was performed and showed the final diagnosis of a stress fracture.     

The burden of femoral shaft fractures in Tanzania

BackgroundRoad traffic injuries disproportionately affect low- and middle-income countries (LMICs) and are associated with femur fractures that lead to long-term disability. Information about these injuries is crucial for appropriate healthcare resource allocation. The purpose of this study is to estimate the incidence of femoral shaft fractures in Tanzania and describe the unmet surgical burden.MethodsStudy sites included six government hospitals across Tanzania. Investigators collected data from hospital admission and procedural logbooks to estimate femoral shaft fracture incidence and their treatment methods. Semi-quantitative interviews were conducted with relevant hospital personnel to validate estimates obtained from hospital records. Investigators gathered road traffic incident (RTI) statistics from national police reports and calculated femur fracture:RTI ratios.ResultsFemoral shaft fracture annual incidence rate ranged from 2.1 to 18.4 per 100,000 people. Median low and high femur fracture:RTI ratio were 0.54 and 0.73, respectively. At smaller hospitals, many patients (5–25%) were treated with traction, and a majority (70–90%) are referred to other centers. Barriers to surgery at each hospital include a lack of surgical implants, equipment, and personnel.ConclusionsThe incidence rate is similar to previous estimations, and it is consistent with an increased femoral shaft fracture incidence in Tanzania when compared to higher income countries. The femur fracture:RTI ratio may be a valid tool for estimating femur fracture incidence rates. There is an unmet orthopaedic surgical burden for femur fractures treatment at rural hospitals in Tanzania, and the barriers to treatment could be targets for future interventions.     

Clinical correlates of atypical femoral fracture

BackgroundReports of atypical femur fracture in bisphosphonate-exposed women have prompted interest in characterizing the clinical profiles of these patients.MethodsAmong women age ≥ 60 years with hip or femur fracture during 2007–2008, we identified 79 with low-trauma subtrochanteric or femoral shaft fracture. Radiographic images were reviewed to assign fracture pattern and distinguish atypical femur fracture from non-atypical femur fracture. Differences in clinical characteristics and pharmacologic exposures were compared.ResultsAmong 79 women (38 subtrochanteric and 41 femoral shaft fracture), 38 had an atypical femur fracture. Compared to those with a non-atypical femur fracture, women with atypical femur fracture were significantly younger (74.0 vs 81.0 years), more likely to be Asian (50.0 vs 2.4%) and to have received bisphosphonate therapy (97.4 vs 41.5%). Similarly, the contralateral femur showed a stress or complete fracture in 39.5% of atypical femur fractures vs 2.4% non-atypical femur fracture, and focal cortical hypertrophy of the contralateral femur in an additional 21.1% of atypical cases.ConclusionsWomen suffering atypical femur fractures have a markedly different clinical profile from those sustaining typical fractures. Women with atypical femur fracture tend to be younger, Asian, and bisphosphonate-exposed. The high frequency of contralateral femur findings suggests a generalized process.     

抗生素骨水泥珠链结合外固定架治疗感染性骨折不愈合

目的：探讨抗生素骨水泥珠链植入结合外固定架固定治疗感染性骨折不愈合的疗效。,方法：回顾分析22例感染性骨折不愈合患者,男20例,女2例;年龄21±74岁,平均（34．7±11．6）岁。骨折部位：股骨粗隆间3例、股骨干6例、股骨髁上2例、胫骨干9例、肱骨干2例。治疗过程分为3个步骤：先取出内固定物,清创后植入抗生素骨水泥珠链,Ⅰ期闭合伤口;1周后再次清创,更换抗生素骨水泥珠链,行外固定架固定;3个月后取出抗生素骨水泥珠链,取髂骨植骨。结果：随访15～28个月,平均（19．98±4．16）个月。1例胫骨干骨折和1例股骨粗隆问骨折患者分别于植骨术后2、3个月感染复发,其余20例患者感染控制良好。22例患者骨折全部愈合,愈合时间为植骨术后8-24周,平均（15．09±4．13）周。结论：彻底清创、抗生素骨水泥珠链植入结合外固定架固定及Ⅱ期植骨是治疗感染性骨折不愈合简单而有效的方法、     

双摇杆技术在成人股骨干骨折复位内固定术中的应用

目的:探讨双摇杆技术在成人股骨干骨折复位内固定术中的应用价值.方法:自2010年9月至2013年6月,采用双摇杆技术克氏针辅助复位交锁髓内钉内固定治疗成人股骨干骨折患者34例,男24例,女10例;年龄17～65岁,平均41岁.病程3～7 d,平均5d.按AO分型,32A型5例,32B型20例,32C型9例.左侧18例,右侧16例.术后随访观察骨折愈合及并发症发生情况,并按照Thorsen股骨骨折术后形态评估标准评价疗效.结果:患者手术时间40～110 min,平均75 min;术中出血200～300 ml,平均250 ml.术中所有骨折获得了良好复位.术后所有患者获随访,时间12～24个月,平均18个月.骨折均愈合,愈合时间4～8个月,平均5个月.均无断钉、感染、骨筋膜室综合征、再骨折、骨折畸形愈合等并发症发生.按照Thorsen股骨骨折术后形态评估标准评定疗效,优30例,良3例,可1例.结论:在成人股骨干骨折复位内固定术中采用双摇杆技术,可使骨折获得良好的复位,缩短手术时间,创伤小,骨折愈合率高,并发症少,患肢功能恢复好,值得临床推广应用.     

Clinical outcomes and affecting factors of ipsilateral femoral neck and shaft fractures - Multination,multicenter analysis

BackgroundThis study aimed to evaluate the clinical outcomes of ipsilateral femoral neck and shaft fractures and identify the risk factors associated with missed diagnosis of femoral neck fractures and clinical outcomes of this fracture.MethodsThe ipsilateral femoral neck and shaft fractures from seven centers were retrospectively reviewed. Data on injury mechanism, fracture pattern, and fracture classification; surgical factors including fixation method; and timing of detection of femoral neck fracture were analyzed. The clinical outcomes, complications, and the incidence of avascular necrosis of the femoral head (AVNFH) were reviewed. Risk factors for missed femoral neck fracture and complications were analyzed.ResultsIn total, 74 patients with an average age of 43.6 years were included. Of the femoral shaft fractures, 56.8% were type A, 21.6% were type B, and 21.6% were type C. Sixteen patients had an open fracture of the femoral shaft. Femoral neck fracture was initially missed in 27% patients and the timing of delayed diagnosis was at an average of 11.1 days after injury. For detecting femoral neck fractures, minimal displacement of the femoral neck fracture was a risk factor, whereas computed tomography (CT) was a protective factor. The incidence of AVNFH was 6.8% at an average of 36.8 months after injury. The AVNFH group had more displaced femoral neck fractures at the time of surgery, but there was no difference in the timing of diagnosis compared to non-AVNFH group. The femoral shaft showed considerable healing problems, with an average union time of 29.7 weeks and a 20.2% nonunion rate.ConclusionIpsilateral femoral neck and shaft fractures had a high rate of missed diagnosis, especially in minimally displaced fractures; however, CT was a protective factor. AVNFH occurred in 6.8% and was related to femoral neck fracture displacement, but not delayed diagnosis. The femur nonunion rate was high, which warrants attention.     

Insufficient bilateral femoral subtrochanteric fractures in a patient receiving imatinib mesylate

We present a case of insufficient bilateral femoral subtrochanteric fractures in a patient who was treated with imatinib mesylate, an anticancer drug, for 1 year after a diagnosis of chronic myelogenous leukemia (CML). A 60-year-old woman presented with bilateral thigh pain for 6 months. A plain radiograph revealed bilateral progressive insufficient fractures on the subtrochanteric areas of the femurs. MRI of the femurs revealed incomplete stress fractures and no evidence of bone metastasis on either femur. Bone densitometry showed normal T-scores around the hip joint and spine. The patient had normal serum levels of calcium, vitamin D derivatives, and thyroid hormones. Serum phosphate levels were decreased, and parathyroid hormone levels were increased. Serum osteocalcin and urinary N-telopeptide of collagen cross-links (NTx) were both decreased. A bone biopsy demonstrated normocellular marrow without leukemic cells. A histomorphometric evaluation of her bones revealed reduced bone turnover despite secondary hyperparathyroidism. The serum markers for bone metabolism and histomorphometric evaluations in this patient suggest that the drug may have an effect on bone metabolism. These effects could be seen for both bone formation and resorption: this could result in impaired bone mineralization, a severely suppressed bone turnover rate, insufficient fractures, and bone necrosis, which are sometimes seen with long-term use of bisphosphonates. To our knowledge, this is the first case of an insufficient bilateral femoral shaft fracture that is potentially related to the use of imatinib mesylate in a patient with CML. Careful examination of bone metabolism should be performed in patients with CML because imatinib mesylate treatment is a lifelong process.     

Stress fracture of the bowed femoral shaft is another cause of atypical femoral fracture in elderly Japanese: a case series

BackgroundWe have studied stress fractures of the bowed femoral shaft (SBFs) among elderly Japanese for over a decade. On the other hand, severely suppressed bone turnover (SSBT) after long-term bisphosphonates (BPs) use has been considered to be one of the causes of low-energy diaphyseal femoral fractures, often called atypical femoral fractures (AFFs). Some studies have shown that BPs use for more than 5 years is associated with an increased risk of AFFs. Here, we present a report of our SBF case series experienced in the past 15 years in order to examine whether bowing deformity should be considered among the causes of AFFs.MethodsSubjects were 13 Japanese female patients with low-energy femoral shaft fractures. Mean age at injury was 77.0 years (range 67–88 years). All patients met the criteria of the AFFs’ case definition. The first author treated 11 of the 13 patients over 8 years (2005–2012) based on the concept of SBFs. Regarding the regional characteristics of these patients, 10 were treated at 2 rural hospitals, and 3 were treated at 3 urban hospitals. Retrospectively, we assessed fracture type and location, existence of fracture on the contralateral side, bowing deformity, and duration of BPs use.ResultsAll 13 cases were AO/OTA type 32-A. Incomplete or previous fracture on the contralateral side was noted in 10 cases. Obvious bowing deformity of the femoral shaft was noted in 12 cases. BPs were taken in 7 cases, only 3 of which involved BPs use for more than 5 years.ConclusionsWe experienced 12 cases of low-energy femoral shaft fractures associated with bowing deformity. Six cases were not treated with BPs at all. Stress fractures associated with a femoral shaft bowing deformity do actually exist and should be recognized as another cause of AFFs.     

Stress Fracture of the Femoral Neck in a Young Female Athlete

Abstract   Stress fractures have been reported to occur in association with running. They typically involve the lower extremity. Although relatively rare, unrecognized or untreated femoral neck fractures carry a much higher morbidity rate than other stress fractures. Stress fractures of the femoral neck should even be considered in young amateur athletes with hip pain. If X-ray is inconclusive, radionuclide bone imaging and MRI can be useful in diagnosing these fractures. This rare diagnosis, as well as classification and treatment options, will be discussed.     

Fractures of the femur and blood transfusions

BackgroundBlood loss estimation after trauma (i.e. physical injury) and early identification of potential sources of bleeding are important for planning of investigation and management of trauma. Long bone fractures have been reported to be associated with substantial volumes of blood loss requiring blood transfusion. The aim of this study was to assess rates and amounts of blood transfusion in the setting of isolated extra capsular femur fractures and to determine variables associated with the need for transfusion within the first 48 h of admission.MethodsA retrospective cohort study was conducted of patients in The Alfred Trauma Registry with isolated extra capsular femur fractures over a 7-year period. We compared patients with a femoral shaft fracture (FSF) to patients with either distal femur or proximal femur fractures (i.e. extremity fracture). We collected data potentially associated with blood transfusion within 48 h as well as operation details and patient outcomes.ResultsThere were 293 patients included, of which 121 had FSF and 172 extremity fracture. 105 (36%) patients received a blood transfusion during their admission. Admission haemoglobin (AOR 0.92; 95%CI 0.89–0.94, p < 0.01) was the only independently associated variable with blood transfusion within the first 48 h of hospital admission.ConclusionVolume of blood transfused to patients with extra-capsular femoral fractures was low and usually in the post-operative period. FSF, compared to femoral extremity fractures, were not more likely to receive blood transfusion within the first 48 h of admission, and did not receive a higher volume of blood overall. In the setting of major trauma with haemorrhagic shock, alternate sources of bleeding should be sought.     

The flipped third fragment in femoral shaft fractures: A reason for open reduction?

ObjectivesFirst introduced by Kuntscher in the 1940s, closed intramedullary nailing of femoral shaft fractures has become the standard of care, with reported union rates up to 99% in some series. However, fractures with large intercalary segments, which are present in 10-34% of femoral shaft fractures, present unique challenges. In particular, how to treat flipped intercalary segments has remained controversial, with some advocating open reduction of these fractures. The purpose of this study was to evaluate the union rates of femoral shaft fractures with flipped intercalary segments treated with closed reduction and intramedullary nail fixation.MethodsA retrospective review of patients with femoral shaft fractures and flipped intercalary segments from January 2000 until January 2018 was performed at a single academic level one tertiary care referral center. All patients between the ages of 16-80 with minimum 6-month follow-up were included. Union rates were evaluated using the radiographic union score of the femur (RUSF). Patients with non-diaphyseal femur fractures, pathologic fractures, incomplete radiographic or clinical follow-up, or open reduction at the time of initial surgery were excluded.ResultsTwenty-six patients (18 male and 8 female) with a mean age of 32 years (SD 12.8, range 19-65 years) and mean follow-up of 15.9 months (range, 6–82 months) met inclusion criteria. Seven patients had open fractures. The mean size of the flipped intercalary segments was 71.3 mm (range: 30-174 mm), with mean displacement of 6.6 mm (range: 1-37 mm). The mean radiographic union scale in femoral (RUSF) at 6 months was 9 (standard deviation: 1.35). There were two patients who went on to non-union. The overall union rate was 92% (24 patients); the non-union rate was 8% (2 patients).ConclusionsThough uncommon, femoral shaft fractures with flipped intercalary segments present unique challenges to surgical treatment. While previous studies have found the presence of large intercalary segments to be associated with higher rates of non-union, the results of this study challenge prior evidence. In conclusion, the presence of flipped intercalary segments may not require different surgical management than the treatment of conventional femoral shaft fractures.Level of evidenceIV     

Bilateral simultaneous femoral diaphyseal fractures in a patient with long-term ibandronate use

Bisphosphonates are the most common medication used to treat patients with documented osteoporosis. Recently, reports have associated long-term bisphosphonate use with low-energy femur fractures. While no definitive mechanism has been associated, bisphosphonate use has been strongly implicated. This article presents the case of a 65-year-old woman with a 2-year history of ibandronate use presenting with simultaneous low-energy femoral shaft fractures. The patient reported prodromal bilateral thigh pain and was seen by a spine surgeon. A review of the literature implicates long-term ibandronate use in low-energy femur fractures. With most of the basic science studies demonstrating suppressed bone turnover after 5 years of treatment with alendronate, the significance of the present case also lies in the relatively short duration of time the patient was on ibandronate before suffering the bilateral femoral shaft fractures. Possible pathophysiology for the fractures includes suppressed bone turnover that may allow microcracks to propagate in cortical bone, which can weaken the bone and possibly predispose it to fractures. Patients who have been on bisphosphonates long term should be questioned about thigh pain and have radiographs of their femurs obtained if pain exists. Furthermore, if a patient presents with a single subtrochanteric or diaphyseal low-energy femur fracture after long-term bisphosphonate use, a radiograph of the contralateral femur should be obtained to assess for a cortical stress reaction.     

Diagnostic accuracy and interobserver variability of plain radiography, subtraction arthrography, nuclear arthrography, and bone scintigraphy in the assessment of aseptic femoral component loosening

Background: Plain radiography, subtraction arthrography, nuclear arthrography, and bone scintigraphy are imaging techniques commonly used to identify aseptic femoral component loosening. Controversy exists about the relative utility of these techniques. Patients and methods: We evaluated the diagnostic accuracy and interobserver reliability of the four techniques in 78 consecutive patients (mean age 70 years, range 29–88 years) referred for evaluation of their femoral hip prostheses. The standard evaluation protocol consisted of plain radiography followed by subtraction arthrography, nuclear arthrography, and bone scintigraphy. Surgery or the subsequent clinical course of the patient was used as gold standard. Results: Overall, plain radiography had a sensitivity and specificity of 81 and 74%, respectively. Subtraction arthrography had a sensitivity of 47% and a specificity of 78%. Nuclear arthrography had a sensitivity of 69% and a specificity of 76%, and bone scintigraphy had a sensitivity of 88% with a specificity of 50%. Conclusion: We found considerable interobserver variability in all four techniques. Multivariate regression analysis revealed that bone scintigraphy and nuclear arthrography together made a significant contribution to the diagnosis when used in combination with plain radiography and are, when plain radiography is inconclusive, useful additional diagnostic techniques for the detection of femoral component loosening.     

Effectiveness of distally slotted proximal femoral nails on prevention of femur fractures during and after intertrochanteric femur fracture surgery

IntroductionIntra- and post-operative femoral shaft fractures related with nailing remain of concern. Although manufacturers have sought to solve the problem by providing distally slotted nails, it is not clear that these implants reduce fractures.We compare two distally slotted proximal femoral nails [trochanteric nail (TRON) and proximal femur intramedullary nail (PROFIN)].Patients and MethodsThe medical records of 195 hips treated with TRONs (distally slotted in four places in the sagittal and coronal planes) and 583 hips treated with PROFINs (distally slotted in two places in the coronal plane) in two institutes were retrospectively evaluated. The inclusion criteria were follow-up for at least 6 months; pertrochanteric fractures and age over 55 years.ResultsIn total, 161 hips in the TRON group and 512 hips in the PROFIN group were included. The mean follow-up time was 28.5 (range: 6–84) months in whole group. The demographic characteristics of the groups were similar. Only 2 intraoperative shaft and 3 proximal lateral cortex fracture was detected in PROFIN group, there wasn’t any postoperative fracture. Four proximal lateral cortex and 2 femur shaft fractures were detected in TRON group (one during operation and one at postoperative 8th month after a fall at pedestrian way).ConclusionsDistal cephalomedullary nail slotting prevented intra- and post-operative femoral fractures. A distal slot 50 mm in length may increase nail elasticity and reduce nail tip stress to a greater extent than a 30-mm slot. Distal slotting in both the sagittal and coronal planes afforded no advantage compared to coronal slotting only.Level of evidenceLevel III retrospective study