Bilateral intertrochanteric and femoral diaphyseal fractures with unilateral proximal tibial fracture: A case report and review of the literature

INTRODUCTION

Bilateral intertrochanteric femur fractures are relatively rare injuries. This study aims to present a case of a patient with simultaneous bilateral intertrochanteric femur fractures and femoral diaphyseal fractures and proximal tibial fracture with his twelve years follow-up.

PRESENTATION OF CASE

A 44-year-old man presented to emergency department after a motor vehicle accident. Bilateral intertrochanteric femur fractures (OTA classification – 31A.1.2) and bilateral femoral diaphyseal fractures (OTA classification – 32A.2) and nondisplaced right proximal tibial fracture (OTA classification – 41B.1) were determined in radiographs. Following closed reduction, fractures were fixed with intramedullary nails bilaterally. Proximal tibial fracture was fixed with cannulated screws following open reduction. At twelfth year follow-up he was able to do his daily activities with minimal limitation.

DISCUSSION

High energy traumas, stress fractures, systemic disorders (osteomalacia, chronic renal failure), steroid treatments, seizures and electric injuries are possible causes for bilateral hip factures. However bilateral femoral diaphyseal fractures are mostly due to high energy traumas. Long-term biphosphonate use may also cause bilateral fractures. Single-stage surgery should be performed in order to avoid secondary damages of surgical interventions. All fractures of our patient were fixed in a single session. This prevented further deterioration of patient''s status and made rehabilitation easy.

CONCLUSION

Careful evaluation of all systems should be performed in multi-trauma patients to find out concomitant injuries. Single staged surgical treatment may decrease morbidities.     

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.     

双侧股骨转子间骨折发病因素分析

目的：通过分析双侧转子间骨折病例资料,了解转子间骨折的致伤因素,为预防多次转子间骨折提供依据。方法：2000年1月至2009年6月研究68例前后两次发生双侧转子间骨折的患者,男31例,女37例;年龄42～95岁,平均75岁。两次骨折AO分型,A1型24髋,A2型96髋,A3型16髋。两次骨折给予手术治疗共128髋,保守治疗8髋。首次骨折治疗康复出院67例,1例因其他并发症转科治疗后出院;再次治疗康复后出院58例,2例死于并发症,8例因其他并发症转科治疗后出院。对前后两次骨折的发病因素进行研究,包括年龄分布、致伤原因、骨折分型、各种伴发的合并症、骨质疏松及治疗情况。结果：患者两次骨折发生平均年龄分剐为（73．6＋9．25）岁和（76．7±6．74）岁;致伤因素以跌倒为主;再次骨折的AO分型A2型上升至80．88％,更加不稳定;合并症比例高,主要为老年认知障碍、脑中风后偏瘫及视觉障碍;16例接受骨密度测定,骨质疏松明显。结论：骨质疏松和跌倒是多次转子间骨折最主要的致伤因素,合并症的存在是重要的危险因素。因此治疗骨质疏松,加强老年患者的护理和术后康复,注意初次手术的效果,是预防老年再次转子间骨折发生的关键。     

Subcapital femoral neck fracture after healing of an intertrochanteric fracture stabilized by an AO-PFN

Summary Subcapital fracture after internal fixation and healing of intertrochanteric hip fracture is a rare identity not previously published in association with the AO-PFN (proximal femur nail).We report an unique case of a 74 year old woman who sustained a displaced subcapital fracture three weeks after uneventful removal of laterally protruded proximal screws without any history of a new trauma. According to the literature osteoporosis seems to be the unique cause for this serious complication. Traumatologists have to pay more importance to detect osteoporosis and its possible complications.     

Bilateral femoral neck fracture following a convulsion in the presence of chronic kidney disease. A case report

Introduction and importanceBilateral femoral neck fractures in young adults are a rare entity. It is usually associated with pre-existing metabolic diseases, such as osteoporosis, renal osteodystrophy, or hypocalcemic seizures. Hence, it is essential in such cases to look for other associated injuries following a traumatic event. Missing associated injuries may lead to significant morbidities and poor functional outcomes.Case presentationA 37 years old male, who had chronic renal failure secondary to hypertension, and presented to the emergency room following a seizure episode, in which he developed a generalized tonic-clonic convulsion secondary to electrolyte imbalances with metabolic acidosis. As a result, he developed bilateral neck of femur fracture.Intervention and outcomeThe medical team optimized electrolytes imbalance and then the patient underwent surgical stabilization of both femur neck fracture, 1 year following the surgical fixation the patient had full range of motion of both hips with radiological evidence of complete healing of the fracture.ConclusionIn cases of fractures secondary to metabolic conditions, bilateral femoral neck fractures should be suspected and investigated; especially in young patients who develop a generalized tonic-clonic seizure. The etiology is multifactorial, and the treating surgeon should be aware of predisposing factors which may affect bone quality, thereby raising the risk of fractures even with low-energy atraumatic events. Hip preservation should always be the primary target when treating these patients.     

Unusual combination of femoral head dislocation associated acetabular fracture with multipart femoral fractures: Case report

IntroductionTraumatic hip dislocation associated with femur intertrocanteric fracture is a rare and severe injury and it frequently occurs following a high energy trauma, Associated acetabular fractures with this injury are even more rare and potentially cause devastating consequences including avascular necrosis of the femoral head and subsequent early secondary osteoarthritis of the hip joint.Presentation of caseIn this case report, we present a 20 year old polytraumatized patient with traumatic hip dislocation associated with ipsilateral acetabulum fracture and simultaneous fractures of the ipsilateral femur.DiscussionTraumatic hip dislocation associated with femur intertrochanteric fracture is a rare and severe injury and it frequently occurs following a high energy trauma. In polytraumatized patients, musculoskeletal injuries are the most common lesions requiring surgical intervention frequently presenting challenging scenarios in terms of functional outcome and quality of life. Osteonecrosis of the femoral head is a serious and unpredictable complication that may occur after displaced femoral neck fracture and traumatic hip dislocation due to the disturbed blood supply of the femoral head.ConclusionA staged treatment strategy may be useful managing an unstable polytraumatized patient or a patient who requires prolonged transfer to receive definitive care.     

Simultaneous bilateral hip fractures following a simple fall in an elderly patient: A case report

Bilateral fractured necks of femur are rare, particularly in the absence of high energy trauma or metabolic bone disease. We describe a case of an 89 year old man with no history of metabolic bone disease who presented with bilateral neck of femur fractures following a simple fall. Clinicians must be vigilant to ensure that bilateral neck of femur fractures are identified and treated appropriately.     

Bilateral irreducible asymmetrical fracture-dislocation of the hip: A case report and literature review

Introduction and importanceBilateral hip dislocation is a rare injury. Bilateral asymmetrical fracture-dislocation is an even rarer type of injury. Apart from its rarity, prompt diagnosis of this condition and emergent treatment is necessary to prevent complications.Case presentationHere we present a 32 years old patient admitted with bilateral asymmetrical dislocation of hips following high energy motor traffic accident.Clinical findings and investigationsComputed tomography revealed bilateral asymmetrical hip dislocations (Left hip anterior dislocation and the right hip posterior dislocation) with a small femoral head fracture on the right side and a large Pipkin I fracture on the left side.Intervention and outcomeClosed reduction of bilateral hips failed under general anaesthesia and rendered immediate open reduction of both hips through different approaches and fixation of the osteochondral fragment. Rehabilitation was challenging as the patient has been recovering from a head injury and bilateral lower limb involvement. The patient is under follow-up for any evidence of avascular necrosis of the femoral heads and myositis ossificans.Relevance and impactBilateral irreducible asymmetrical fracture-dislocations of the hip joint are rarest of its kind. Pre-operative emergent computed tomography is very helpful to identify fracture-dislocations and help in the planning of osteosynthesis. Preparation for open reduction while undergoing a close reduction is essential.     

A new technique of endoprosthetic replacement for osteosarcoma of proximal femur with intra-articular extension

INTRODUCTIONOsteosarcoma is the most common primary malignant tumour of bone and commonly involved sites are the distal femur, proximal tibia, and humerus. Osteosarcoma of proximal femur usually arises at the metaphysis and articular cartilage acts as a relative barrier to tumour spread, with extension into the hip joint being extremely rare.PRESENTATION OF CASEA previously fit and well sixteen-year-old male presented with a 2 month history of right hip pain and a limp. Plain radiographs and magnetic resonance imaging (MRI) showed an expansile lesion in the right femoral neck, extending 16 cm distally from the proximal femoral articular surface through the intertrochanteric region into the upper right femoral shaft. There was also clear evidence of intra-articular extension into the acetabulum.DISCUSSIONEndoprosthetic replacement following resection is a good treatment option for proximal femoral tumours due to the low complication rate and achievement of good postoperative function. However, treatment of a proximal femoral lesion with intra-articular involvement by prosthetic reconstruction is challenging. We report a patient who presented with osteosarcoma of the proximal femur extending into the hip joint and describe the technique of en-bloc extra-articular resection of the acetabulum and proximal femur with reconstruction using a custom made prosthesis.CONCLUSIONWe conclude that extra-articular resection and endoprosthetic reconstruction using a coned hemi-pelvic implant with fluted stem and a modular femoral implant is a useful treatment option in the management of a proximal femoral lesion involving the hip-joint. It allows adequate tumour clearance and stable reconstruction for rapid post-operative recovery with early mobilisation.     

偏心固定与髓内固定治疗股骨转子间骨折的病例对照研究

目的 :比较股骨转子间骨折采用偏心固定及髓内固定两种方法的疗效,为股骨转子间骨折治疗方法的选择提供理论依据。方法:2007年2月至2010年1月收治股骨转子间骨折患者82例,其中偏心固定组39例,男16例,女23例,年龄41~81岁,平均(62.68±10.69)岁,采用动力髋或股骨近端锁定钢板固定;髓内固定组43例,男15例,女28例,年龄43~78岁,平均(62.60±8.37)岁,采用PFN或PFNA固定。比较两组患者的切口长度、手术时间、术中出血量以及术后Harris评分情况。结果:两组伤口均Ⅰ期愈合,无手术并发症。82例患者均获得随访,时间12~28个月,平均18.3个月。两组切口长度、手术时间、术中出血量差异具有统计学意义。两组术后1个月Harris髋关节功能评分比较差异有统计学意义(P<0.05),而术后12个月Harris髋关节功能评分差异无统计学意义(P>0.05)。偏心固定组优良率为89.7%,髓内固定组优良率为90.7%,差异无统计学意义(P>0.05)。偏心固定组骨折不愈合1例,动力髋主钉螺丝松动并继而发生髋内翻畸形。髓内固定组无防旋钉退出,髓内钉远端股骨再骨折1例。结论:两种方法治疗股骨转子间骨折均有良好疗效,但是髓内固定较偏心固定手术时间更短,出血量更少,适用于骨质疏松和不稳定型股骨转子间骨折的治疗。     

老年髋部骨折术后对侧髋部再骨折的危险因素分析

目的 :探讨老年髋部发生二次骨折的相关风险因素,为预防对侧髋部再骨折提供临床依据。方法 :回顾性分析2008年12月至2014年2月378例老年髋部初次骨折患者的资料,男175例,女203例;年龄60~90岁,平均(75.53±8.04)岁;股骨颈骨折125例,股骨粗隆间骨折253例。术后随访12~36个月,平均24.9个月,32例患者发生对侧髋部再骨折,男13例,女19例;年龄72~95岁,平均(81.25±5.94)岁;股骨颈骨折7例,股骨粗隆间骨折25例。根据患者术后有无对侧髋部再骨折分为骨折组和无骨折组,比较两组患者的年龄、性别、初次骨折类型、内固定方式、卧床时间、骨质疏松情况、合并内科疾病情况、术后功能锻炼、治疗的依从性、生活环境(农村/城市)和末次随访时Harris评分,对于P0.05的因素进行多因素Logistic回归性分析。结果:骨折组与无骨折组的年龄、骨质疏松情况、合并内科疾病情况、术后功能锻炼、医疗依从性及末次随访时Harris评分比较差异均有统计学意义(P0.05)。多因素Logistic分析结果显示:骨质疏松(OR=6.793,P=0.001),高龄(OR=4.170,P=0.002),合并内科疾病(OR=3.828,P=0.005),术后功能锻炼(OR=0.297,P=0.005)以及医疗依从性(OR=0.295,P=0.007)是老年髋部骨折术后对侧髋部再骨折的主要危险因素。结论:老年髋部骨折术后对侧再骨折主要危险因素是高龄、骨质疏松、合并内科疾病、术后功能锻炼和医疗依从性。术后需加强抗骨质疏松治疗、积极治疗内科疾病,坚持功能锻炼,以预防髋部再次骨折的发生。     

Late-diagnosed bilateral intertrochanteric femur fracture during an epileptic seizure

Although spontaneous and simultaneous bilateral hip fractures without trauma are seen rarely, epileptic seizures may lead to these fractures. We present an 82-year-old female patient with poor bone quality and a 20-year history of epilepsy. She had been using anticonvulsant drugs for almost 20 years. Following a convulsive epileptic attack, bilateral intertrochanteric femur fractures occurred (causing bilateral hip pain), which was diagnosed on the 12th day. An earlier pelvic anteroposterior roentgenogram would be helpful for early diagnosis. It should not be forgotten that bone fractures may be observed without trauma in epilepsy patients.     

Spontaneous subcapital femoral neck fracture complicating a healed intertrochanteric fracture

A spontaneous subcapital femoral neck fracture is an uncommon complication of a healed intertrochanteric hip fracture. To determine the etiology of this complication, 274 patients who had been treated for intertrochanteric hip fractures were followed up over an 8-year period from June 1988 to June 1996. We found 7 fractures of the subcapital femoral neck without a history of a trauma. The remaining 267 patients were defined as the control group. All seven patients with fractures of the subcapital femoral neck were women, and their average age at the time of compression hip screw (CHS) fixation was 83 years (range 74-92 years). The subcapital fractures occurred between 4 and 36 months after CHS fixation. The difference in the Singh index between the patient and control groups was statistically significant (P < 0.01). However, with regard to the position of the screw, spinal score, age, ambulatory ability, height, weight, and intertrochanteric fracture type (Jensen type), the differences between the patient and control groups were not statistically significant. Based on our findings, we conclude that a high grade of osteoporosis is the most important predisposing factor in the spontaneous development of a subcapital femoral neck fracture after a healed intertrochanteric hip fracture.     

High prevalence of vitamin D deficiency and osteoporosis in patients with fragility fractures of hip: A pilot study

BackgroundVitamin D deficiency (VDD) is a major cause of poor bone health that could lead to fragility fractures, however, there is paucity of literature on prevalence of VDD and associated bone mass in patients of fragility fractures. Hip and spine are the commonest region affected by these fractures and the present study was conceptualised to ascertain the prevalence of VDD and bone mass in patients of hip fragility fractures (proximal femur) to evaluate their role in incidence of these fractures.Methods and materialsBetween January 2013 and December 2013, 66 patients of fragility fractures around hip with age more than 50 years presented to our out patient department. Baseline evaluation of calcium profile, renal function tests, parathyroid hormone and 25(OH)D were done. All patients underwent DXA scan of the non -fractured hip.ResultsTotal number of male patients was 29 and females was 37, with mean age of 64.1 and 70.3 years, respectively. Intertrochanteric femur fractures were the most common type with 35 cases. Fall in bathroom was the most common mode of injury with 36 cases (54.5%). VDD was found in 74.2% of all patients. Prevalence of secondary hyperparathyroidism was observed in 27 patients. Osteopenia, osteoporosis and severe osteoporosis were observed in 15.2%, 62.1% and 18.2% of patients respectively. Sun light exposure was inadequate in 59% of patients with only 1 female patient having adequate exposure.ConclusionPrevalence of Vitamin D deficiency is very high in patients with hip fragility (proximal femur) fractures with secondary hyperparathyroidism and osteoporosis commonly associated. These fractures in our part of the world, occur at a younger age group as compared to the Western population. Majority of the patients sustain in-house fractures.     

Bilateral Mid-Diaphyseal Femoral Stress Fractures in the Elderly

Abstract Background: Osteoporosis is characterized by low bone density and poor bone mineralization. Mid-diaphyseal stress (insufficiency) fractures of the femur caused by osteoporosis are rare. The symptoms of these lesions are vague and confusing. The physician must be alert to the possibility of femoral shaft stress fractures when evaluating an elderly patient complaining of back, hip or leg pain. Case Study: A 72-year-old osteoporotic female patient with bilateral mid-diaphyseal stress fractures of the femur is reported. The diagnosis of femoral shaft stress fracture in the elderly is very difficult when based on physical findings and plain radiography only. A magnetic resonance imaging (MRI) scan or nuclear scintigraphy is necessary for early diagnosis. In the described case, the patient had an excellent result after surgical treatment with intramedullary nails. Conclusion: MRI or nuclear scintigraphy must be obtained to exclude the possibility of femoral shaft stress fractures in the elderly. In the absence of contraindications, surgery is the best solution for this kind of lesion.     

股骨粗隆间骨折不同内固定方法的回顾性比较

目的：比较不同内固定方法在治疗股骨粗隆间骨折中的优缺点,探讨股骨粗隆间骨折内固定选择的策略。方法：股骨粗隆间骨折患者326例行内固定手术,其中动力髋螺钉（dynamic hip screw）固定（DHS组）165例,男78例,女87例,年龄38～98岁;股骨近端解剖钢板（anatomic plate）固定（AP组）103例,男48例,女55例,年龄39～89岁;可膨胀股骨近端钉（proximal femoral nail）固定（PFN组）58例,男31例,女27例,年龄41～92岁。根据Evans股骨粗隆间骨折分型分为I、II、III、IV型及逆粗隆间骨折共5型,各组病例数分别为DHS组（12、35、61、42、15）,AP组（9、23、38、25、8）,PFN组（6、13、21、13、5）。比较上述3组在手术时间、术中出血量、术中X线暴露次数、术后引流量、骨折临床愈合时间、术后功能评分、手术并发症等方面的结果。结果：DHS、AP和PFN组在手术时间、术中出血量、术中X线暴露次数、术后引流量、骨折临床愈合时间、术后功能评分等方面差异有统计学意义（P〈0.01）,PFN组较DHS、AP组手术时间缩短、术中出血量和术后引流量少、骨折临床愈合时间缩短、术后功能恢复好,但术中X线暴露次数明显多。各组手术并发症的差异无统计学意义（P=0.05）。结论：可膨胀股骨近端钉在治疗股骨粗隆间骨折中具有一定的优势。     

伴有后方冠状面骨折的A2.3型股骨转子间骨折的临床特点和治疗

目的 :探讨伴有后方冠状面骨折的A2.3型股骨转子间骨折的特点、手术技巧和疗效。方法:2011年1月至2014年1月,采用股骨近端防旋髓内钉治疗33例伴有后方冠状面骨折的股骨转子间骨折的患者,其中男15例,女18例;年龄61~92岁,平均(73.1±8.2)岁;按照AO/OTA分型,均为A2.3型;均为闭合性骨折。均采取有限切开辅助复位内固定术,采用Harris髋关节评分标准对术后疗效进行评价。结果:1例术后19 d死亡,32例获得随访,随访时间9~24个月,平均(16.3±5.1)个月;根据X线片随访,骨折愈合时间6~9个月,平均(7.2±1.5)个月。末次随访Harris髋关节功能评分为76~95分,平均(85.3±5.6)分;其中优13例,良16例,可3例。结论:伴有后方冠状面骨折的A2.3型股骨转子间骨折类型特殊,复位困难,又相当不稳定,需使用辅助切口复位,并采用近端抗旋髓内钉固定,术后康复锻炼亦需个体化。     

Pregnancy-related hip diseases: incidence and diagnoses

BackgroundPregnancy-related hip diseases epidemiology has been poorly evaluated. We report our experience of gestational and postpartum hip diseases and evaluate their incidence.Methods(1) Prospective survey: all pregnant or early postpartum women suspected to have hip involvement during their follow-up in an Obstetric unit were referred to a rheumatologist. If clinically confirmed, magnetic resonance imaging (MRI) and additional investigations as needed were performed. This survey had 2 years duration. (2) Retrospective study: all cases of definite (with MRI confirmation) pregnancy-related hip disease referred to our Rheumatology unit during the past 15 years were analyzed.ResultsDuring the 2-year prospective survey, 3 patients (4 hips) of pregnancy-related hip disease were observed over 4900 pregnancies (1 case of transient osteoporosis of the hip (TOH) and 2 cases of occult fracture of the femoral head). During the 15-year retrospective study, 12 patients (17 hips) with hip diseases during pregnancy or early postpartum were identified. There were 6 patients (9 hips) with TOH, 4 patients (6 hips) with occult fracture of the femoral head, 1 patient with osteonecrosis of the femoral head, and 1 coxitis in a patient with ankylosing spondylitis. Differentiating diagnosis between TOH and occult fractures could only be made by MRI. Five of the 6 women with TOH had osteopenia at the lumbar spine at dual energy X-ray absorptiometry (DEXA). The 4 women with occult fractures had either osteopenia or osteoporosis at the lumbar spine.ConclusionHip diseases are infrequent during pregnancy and early postpartum. Transient osteoporosis of the hip and occult stress fractures of the femoral head appear the main causes and those diagnoses justify evaluation for an underlying bone fragility. Osteonecrosis is very rare in this setting.     

Single screw type of lag screw results higher reoperation rate in the osteosynthesis of basicervical hip fracture

BackgroundBasicervical hip fractures are relatively rare with greater biomechanical instability compared to the other types of hip fractures. Several studies have reported ambivalent surgical outcomes of basicervical hip fractures. The purpose of this multicenter study was to analyze surgical outcomes of basicervical hip fractures according to the fixation type of proximal femur and lag screw type.MethodsAmong 3220 hip fractures, 145 were classified as basicervical hip fractures. Of those, 106 patients treated with osteosynthesis were included to analyze the surgical complications according to fixation type of proximal femur: sliding hip screw(SHS) and cephalomedullary nail (CMN) groups. Surgical complications including the excessive displacement of fracture and the occurrence of reoperation were evaluated at the final follow up. We further evaluated surgical complications according to lag screw type with subgroup analysis in CMN group: single screw type, blade type and two integrated screw type.ResultsTen patients (9.4%) sustained surgical complications (5 excessive displacements and 5 reoperations). For fixation type of proximal femur, SHS group showed higher tendency of excessive displacement despite no statistical difference between the two groups (p = 0.060). For lag screw type with subgroup analysis in CMN group, single screw type showed statistically high rates of reoperation compared to the other types of lag screw (p = 0.022).ConclusionBasicervical hip fractures treated with osteosynthesis resulted to high rates of surgical complications in this study. However, they could be drastically reduced if CMN with blade type or two integrated screw type were used in the osteosynthesis of basicervical hip fractures.     

Improving Femoral Bone Density Measurements

Femoral bone density measurements are clinically important because of their strong relationship with hip fracture. However, current densitometers have not improved upon femoral densitometry since the introduction of dual-energy X-ray absorptiometry (DXA) systems. Recently, several advances in DXA measurement of the proximal femur have been proposed by various published studies. These advances can be added to existing DXA systems, while maintaining the conventional femoral regions of interest. Both upper neck bone mineral density (BMD) and hip axis length have been reported to be associated with hip fractures. With newer technology that enables a rapid assessment of both hips, bilateral femur measurements are now clinically practical and are of importance in those with T-scores approaching, yet not reaching, diagnostic or therapeutic thresholds. Bilateral femur measurements also reduce precision error compared to a single femur measurement, yielding precision errors less than observed at the spine. With this decrease in precision error, monitoring of bone changes is now possible at the femur with the utility comparable to the spine.