Úvod: Magnetická rezonance (MR) je používána v oblasti proximálního femuru k diagnostice okultních či inkompletních zlomenin krčku femuru a trochanterického segmentu více jak 20 let. Spolehlivost této metody byla opakovaně prokázána řadou studií vč. jejích výhod proti CT. MR tak pomohla racionalizovat léčbu okultních a inkompletních trochanterických zlomenin. Metoda: Do studie bylo zařazeno celkem 13 pacientů vyšetřených MR pro suspektní okultní či inkompletní zlomeninu trochanterického masivu během první 24 hod po úrazu. Vždy se jednalo o první poranění kyčelního kloubu, druhý kyčelní kloub byl intaktní. Výsledky: Frontální skeny prokázaly v oblasti linea intertrochanterica (přední kortikalis) výraznou lomnou linii, která probíhají od velkého trochanteru mediodistálně do mediální kortikalis femuru. Sklon lomné linie se však v předozadním směru měnil a těsně před zadní kortikalis byl téměř vertikální. Sagitální skeny zobrazily lomnou linii začínající ve velkém trochanteru, pokračující mediálně a oddělující zadní kortikalis od trochanterického segmentu. Závěr: Analýza MR nálezů prokázala, že primární lomná linie u pertrochanterických zlomenin vzniká v oblasti velkého trochanteru, odkud se šíří současně distálně, mediálně a anteriorně k přední kortikalis v oblasti linea intertrochanterica a k trochanter minor. Velký trochanter tak představuje locus minoris resistentiae a je vždy rozlomen na více fragmentů, než je patrné na RTG snímku.
Background and study aims: Magnetic resonance imaging (MRI) has been used for more than 20 years in the region of the proximal femur to diagnose occult, or incomplete, fractures of the femoral neck and the trochanteric segment. MRI has also potential to contribute to the understanding of the pathogenesis and pathoanatomy of trochanteric fractures. Methods: The group including 13 patients was examined by MRI for a suspected, or incomplete, fracture of the trochanteric segment within 24 hours post-injury. In all cases, this was the first injury to the hip joint, with the other hip joint remaining intact. Results: The coronal scans showed a marked fracture line which, in the region of the intertrochanteric line, extended from the base of the greater trochanter (GT) medially and distally and involved the medial cortex. This inclination, however, was gradually changing posteriorwards and close before the posterior cortex. The fracture line was passing vertically along the lateral trochanteric wall as far as the level of the lesser trochanter (LT). Then the fracture line changed its course and ran horizontally to the cortex of the LT. Sagittal scans showed clearly the primary fracture line originating in the greater trochanter, extending medially and starting to separate the posterior cortex. Conclusion: Analysis of MRI findings has documented that the primary fracture line in pertrochanteric fractures originates in the GT and extends distally, medially and anteriorly towards the anterior cortex, the intertrochanteric line and the LT. Thus, the GT presents a rather vulnerable site and is always broken into more fragments than shown by a radiograph.
Zlomeniny proximálního femuru jsou jedny z nejčastějších zlomenin. Patří sem zlomeniny krčku femuru a zlomeniny trochanterického segmentu. Průměrný věk pacientů se pohybuje kolem 80 let a téměř tři čtvrtiny tvoří ženy. To znamená, že zlomeniny proximálního femuru jsou problémem nejen terapeutickým, ale i sociálním a ekonomickým. Až na výjimky je léčba zlomenin proximálního femuru operační. U zlomenin krčku femuru převažuje aloplastika, u trochanterických zlomenin osteosyntéza. Nejčastější komplikací osteosyntézy u zlomenin krčku femuru je avaskulární nekróza hlavice femuru, u trochanterických zlomenin je to mechanické selhání osteosyntézy.
Fractures of the proximal femur are among the most common fractures. They include fractures of the femoral neck and fractures of the trochanteric segment. The average age of patients is around 80 years and almost three quarters are women. This means that proximal femur fractures are not only a therapeutic problem, but also a social and economic issue. But for few exceptions, proximal femur fractures are treated operatively, with arthroplasty prevailing in femoral neck fractures and internal fixation in trochanteric fractures. The most common complication of internal fixation in femoral neck fractures is avascular necrosis of the femoral head, in trochanteric fractures it is mechanical failure of internal fixation.
BACKGROUND: Recent pathoanatomic studies based on 3D CT reconstructions have questioned validity of AO/OTA classification because it does not reflect the reality and requires revision. These 3D CT studies, however, do not allow analysis of all details. Therefore, we have exploited the possibility to analyze the pathoanatomy of pertrochanteric fractures on postmortem specimens. MATERIAL AND METHODS: From the collection of the Institute of Anatomy, the authors obtained 16 specimens of hip joints of individuals who had sustained a pertrochanteric fracture and died within 30 days of the injury, with anteroposterior radiographs of the injured hip available in all of them. The number of major fragments and their shape, and the courses of the main fracture lines were studied. RESULTS: Three major fragments (a proximal head and neck fragment, a distal diaphyseal fragment and a posterior flat fragment), separated by three types of fracture lines (primary, secondary and tertiary lines) were identified. The primary line separated the proximal fragment (head and neck) from the distal diaphyseal fragment. The secondary fracture line separated the posterior flat fragment from the distal diaphyseal fragment. The tertiary fracture line split the posterior fragment into two parts. A key factor for fracture instability is the defect of the posterior cortex, which depends on the size and shape of the posterior fragment. Avulsion of the lesser trochanter and the adjacent cortex results in an unstable configuration of fracture lines on the medial side, while on the lateral side a large posterior fragment weakens the lateral trochanteric wall. CONCLUSION: In agreement with recent CT studies, the findings of this pathoanatomical study change, in a number of aspects, the traditional view of the pathoanatomy and classification of pertrochanteric fractures, and introduces the concept of three, instead of the traditional four, main fragments.
BACKGROUND: Femoral posterior hip dislocation with associated femoral head fractures (Pipkin fractures) are rare high-energy injuries. Published treatment modalities involve conservative treatment, head fragment resection, open reduction and internal fixation, and total hip replacement. The experience with mini-invasive screw osteosynthesis of these fractures is the main focus of our study. METHODS: Seven Pipkin fractures (five Pipkin II and two Pipkin I) in six patients were treated by closed reduction of hip dislocation, followed by minimal invasive lag screw osteosynthesis. Cancellous screw(s) were inserted from the incision on the lateral hip through the femoral neck to the reduced fracture fragment. In all patients, postoperative CT was performed to check the quality of surgery. Active physiotherapy with immediate toe-touch weight bearing was the routine postoperative protocol. In all patients, radiological and clinical results were evaluated with the Thompson Epstein, Merle d'Aubigne and Postel score, and Harris hip score. RESULTS: All fractures united, and all femoral heads survived. Infectious complications were not observed, and no secondary surgery was needed. After an average follow-up of 18.4 months, the average Merle d'Aubigne and Postel score was 17.7 points, while the mean Harris hip score reached 98.1 points. The majority of patients achieved an excellent Thompson-Epstein clinical and radiological outcome. All patients returned to their original occupation. CONCLUSIONS: Mini-invasive screw osteosynthesis can be used for the treatment of Pipkin type I-II femoral head fractures. Successful reduction of hip dislocation and head fracture is necessary for using this technique. Long-term follow-up is necessary to confirm this technique.
- MeSH
- fraktury femuru * komplikace chirurgie MeSH
- fraktury kyčle * diagnostické zobrazování chirurgie komplikace MeSH
- hlavice femuru diagnostické zobrazování chirurgie zranění MeSH
- kostní šrouby škodlivé účinky MeSH
- lidé MeSH
- luxace kyčle * komplikace chirurgie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
PURPOSE: Functional results after internal fixation of trochanteric femoral fractures may be negatively affected by healing in a non-physiological position. The aim of this study was to evaluate the occurrence and severity of femoral malrotation after nailing of trochanteric fractures. MATERIALS AND METHODS: The authors conducted a prospective study focused on a CT analysis of malrotation after intramedullary nailing of trochanteric fractures (AO 31A1-3) in 101 patients. We recorded the type of fracture, method of anesthesia, scheduled surgery vs. acute surgery, and the surgeon's experience as possible risk factors for limb malrotation after trochanteric fracture surgeries. RESULTS: The average extent of malrotation was 9° of internal rotation ranging from 29° of external to 48°of internal rotation. In 35% of patients, we observed a rotation greater than 15°, and in 15 patients (15%), the rotation was greater than 25°. The risk of significant internal malrotation was significantly higher than external malrotation (37 vs. 4 patients). None of the factors observed proved to be statistically significant. The effect of general anesthesia and the type of intertrochanteric fracture came closest to having a significant effect on rotational error. CONCLUSION: Improper reduction of a trochanteric fracture is a common problem that can lead to femur malrotation. In our study, a rotational error greater than 15° occurred in 35% of the patients, but none of the monitored factors represented a statistically significant risk for this complication.
- MeSH
- femur diagnostické zobrazování chirurgie MeSH
- fraktury femuru * diagnostické zobrazování etiologie chirurgie MeSH
- fraktury kyčle * komplikace diagnostické zobrazování chirurgie MeSH
- intramedulární fixace fraktury * škodlivé účinky metody MeSH
- kostní hřeby škodlivé účinky MeSH
- lidé MeSH
- počítačová rentgenová tomografie MeSH
- prospektivní studie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
PURPOSE OF THE STUDY The intertrochanteric femur fractures seen in the elderly population are usually treated surgically. Mechanical failure of this treatment is a serious complication and to prevent this, many assessment factors have been described such as tip-apex distance, reduction quality etc. The aim of this study is to evaluate the intra- and inter-observer reliability of modifiable factors evaluated after the treatment of intertrochanteric fractures. MATERIAL AND METHODS The early post-operative radiographs of sixty-two patients treated with PFN-A were evaluated. Six observers with 8 to 27 years of experience in hip trauma surgery were asked to measure tip apex distance (TAD), calcar referenced TAD (calTAD), collo-diaphyseal angle (CDA) and evaluate the position of helical blade and also fracture reductions according to Baumgaertner and Chang criteria on these radiographs. Fleiss kappa and intra-class correlation coefficient (ICC) values were calculated for inter-observer and intra-observer reliability assessment, respectively. RESULTS Inter-observer reliability values for both evaluations were moderate (fleiss κ: 0.417-0.455) for TAD measurements, moderate (fleiss κ: 0.418-0.458) for calTAD measurements, fair (fleiss κ: 0.302-0.288) for CDA measurements, substantial (fleiss κ: 0.606-0.631) for antero-posterior zone evaluation, moderate (fleiss κ: 0.550-0.546) for lateral zone assessment, fair-moderate (fleiss κ: 0.353-0.453) for Baumgaertner reduction quality assessment, and fair-moderate (fleiss κ: 0.365- 0.456) for Chang reduction quality assessment. Intra-observer reliabilities were found to be moderate to good for TAD and calTAD measurements, moderate for CDA measurements, good to excellent for AP and lateral zone and Baumgaertner reduction quality criteria assessments and good for Chang reduction quality criteria assessment. DISCUSSION There is no large data on the subject of the present study in the literature. There is a single article evaluating the reliability of more than one evaluation criteria in which only two observers' findings were evaluated in the literature. As in our study, more accurate inferences can be made with the increase in the number of observers. Unlike the literature, the inter-observer reliabilities of TAD and calTAD which have a very important place in the postoperative evaluation of these fractures were found as "moderate'' instead of "excellent'' in our study, CONCLUSIONS It was determined that only the inter-observer reliability of antero-posterior zone evaluation was substantial. The inter-observer reliability of all other measurements and evaluations were fair to moderate. Key words: Intertrochanteric fractures, reliability, measurements, reduction quality; TAD, calTAD.
PURPOSE OF THE STUDY In this study we aimed to investigate the clinical and radiographic results of AO/OTA 31 A3 fractures operated on with either a proximal femoral lateral locking plate or short cephalomedullary nails. MATERIAL AND METHODS/RESULTS Medical data of patients treated with either implant were evaluated retrospectively. Patients > 55 years old sustaining an AO 31 A3 type fracture with a minimum follow-up of one year from two institutions were included in the study. RESULTS In all, 22 patients in the plate group and 30 patients in the nail group were included. All patients achieved union excluding the patients with failure. No significant differences in the mean duration of surgery, pre- and postoperative hemoglobin levels, duration of union time, or need for an open reduction or revision surgery were observed between the two groups. Reduction quality was better in the nail group. Failure of fixation was detected in three patients in the plate group and in four patients in the nail group. The duration of hospital stay was longer in the plate group than the nail group (p = 0.007). Time to independent mobilization was significantly shorter in the nail group than the plate group (p = 0.027). The Harris hip score results were similar between the groups after one year (p = 0.479). CONCLUSIONS Both implants had similar radiographic and clinical outcomes treat 31 A3 intertrochanteric fractures if the lateral wall of the proximal fragment was intact and anatomical medial-posteromedial restoration of the fracture is performed. Although complication rates were similar between the two groups, nails enabled early mobilization of patients. Key words: intertrochanteric, 31 A3 fracture, fixation, PFLP, nail.
- MeSH
- fraktury femuru * diagnostické zobrazování chirurgie MeSH
- fraktury kyčle * diagnostické zobrazování chirurgie MeSH
- intramedulární fixace fraktury * škodlivé účinky MeSH
- kostní hřeby MeSH
- lidé středního věku MeSH
- lidé MeSH
- nehty MeSH
- retrospektivní studie MeSH
- výsledek terapie MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
PURPOSE OF THE STUDY The study gives a retrospective assessment of the outcomes of surgical treatment in patients who sustained a subtrochanteric fracture. MATERIAL AND METHODS In the period 2010-2018, a total of 118 patients with a subtrochanteric fracture, namely 75 males and 43 females, the mean age 61 years, were treated at our department. The study group included the patients who met the following inclusion criteria: age 18+, fracture treated by intramedullary nailing, follow-up for at least 12 months, in case of impaired healing and need for revision surgery follow-up until complete healing was achieved. Exclusion criteria - pathological fractures, periprosthetic fractures, pertrochanteric fractures with extension into subtrochanteric region, intertrochanteric fractures, fractures during bisphosphonate treatment, incomplete radiological documentation, non-compliance with the condition of 12-month follow-up. In 54 patients (46%) the injury was caused by high-energy impact, in the remaining 64 patients (54%) the fracture was the consequence of low energy mechanism. In 51 patients (43%) closed reduction was performed and 67 patients (57%) underwent open reduction. In 27 patients (23%) a small incision laterally was necessary to insert the reduction instrument in order to achieve correct position of the fracture. In 40 patients (34%) lateral approach was used for the reduction and proper placement of fragments was ensured by one or more cerclage wires prior to nailing. Nails made by Synthes were used for osteosynthesis: PFN A Long in 95 patients, PFN A in 11 patients and LFN in 12 patients. RESULTS In 76 patients (64%) fractures healed within 6 months, in 107 patients (90%) within 9 months. In 11 patients (10%) nonunion was observed that required another surgery. The outcomes were assessed using the Sanders and Regazzoni scoring system. Excellent outcome was achieved in 79 cases (67%), good outcome in 25 cases (21%), satisfactory outcome in 13 cases (11%), poor outcome in 1 case (1%). DISCUSSION At any age subtrochanteric fractures are always treated surgically. Currently, intramedullary nailing is the method of choice. The outcome of the surgery depends on correct reduction and fixation which shall ensure the balance of compression forces transmitted to the medial cortical bone, traction forces transmitted to the lateral femoral cortical bone. Intramedullary nailing has biomechanical advantages which outweigh the often difficult closed reduction. The nail decreases the position vector (of the force moment) and reduces torsional forces at the fracture site. Open reduction and additional cerclage wires are described as a risk factor for impaired healing. Nevertheless, the achievement of anatomical reduction offsets the risk of poor blood supply at the fracture site. Persistent displacement disturbs the balance of forces and results in impaired healing and implant failure. CONCLUSIONS Treatment of subtrochanteric fractures relies on precise reduction. Today, when minimally invasive methods of treatment are preferred, the most commonly used are the intramedullary implants. Displacement to varosity, flexion displacement or a combination of both cause impaired healing with non-union and failed osteosynthesis. Treatment of non-union is extremely challenging and always consists in the correction of anatomical relationships. Key words: subtrochanteric fractures, surgical treatment, outcomes, complications.
- MeSH
- fraktury kyčle * diagnostické zobrazování chirurgie MeSH
- hojení fraktur MeSH
- intramedulární fixace fraktury * škodlivé účinky MeSH
- kostní dráty MeSH
- kostní hřeby MeSH
- lidé středního věku MeSH
- lidé MeSH
- retrospektivní studie MeSH
- vnitřní fixace fraktury MeSH
- výsledek terapie MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
PURPOSE OF THE STUDY Continuous epidemiologic data on changes in the spectrum of acetabular fractures is rare. The purpose of this study is to evaluate changes in the types of acetabular fractures over the last two decades. MATERIAL AND METHODS In the period between 2007 and 2016, a total of 522 patients were treated at the authors department (Traumacentre Level I) for acetabular fractures. 15 patients sustained bilateral fractures. The group consisted of 361 men and 161 women, with the mean age of 49 years (the range of 10-96 years). Standard procedure was applied to diagnose the fractures (X-ray and CT scan). Non-operative treatment was opted for in fractures without displacement, fractures with minimum displacement of acetabular weight bearing area less than 2 mm, confirmed by the CT scan (e.g. low fractures of anterior column, low transverse fractures), fractures with secondary congruence in patients over the age of 70, and fractures in patients contraindicated for surgery due to their serious overall medical condition or severe osteoporosis. A surgery was indicated in case of instability or incongruent acetabular joint space due to the displacement of weight bearing area fragments, or a bone fragment or soft tissue interposition. A surgery was indicated also in a non-displaced acetabular injury with concurrent femoral head injury. AO/ASIF classification was used to classify the fractures. The following data was monitored in the referred to group of patients: gender, age, mechanism of injury, associated injuries, type of fracture, and treatment method. RESULTS Type A fracture was reported in 293 patients (56%), type B fracture in 150 patients (29%) and type C fracture in 79 patients (15%). A high-energy trauma occurred in 334 patients (64%), namely 254 men and 50 women, with the mean age of 41 years. A low-energy trauma was sustained by 188 patients (36%), namely 77 men and 111 women, with the mean age of 69 years (56-91). This difference in the share of men and women with respect to the seriousness of the mechanism of injury was statistically significant (p < 0.0001). Non-operative treatment was used in 248 patients (48%), of whom 167 were men and 81 were women. The mean age in this sub-group was 60 years, namely 58 years in men and 62 years in women. Operative treatment was opted for in 272 patients (52%), of whom 206 were men and 50 were women, with the mean age of 45 years in women as well as in men. The statistical processing of differences between the non-operative and operative treatment in dependence on the type of fractures revealed a significantly higher percentage of operative treatment in type C fractures compared to type A and B fractures (p < 0.0001, or p = 0.0009). In the group of patients treated by the authors in the 1996-2002 period, type A fractures constituted 45% of all fractures, where A1 fractures prevailed with 29%, A2 fractures represented 9% and A3 fractures only 6 %. In the recent group of patients, type A fractures constituted 56%, but A3 fracture were seen in 29% of patients, which was a significant increase (p < 0.0001). A3 fractures (anterior wall or anterior column fractures) were associated with a low-energy mechanism of injury and occurred in 48% of patients (73, mostly elderly women). DISCUSSION When compared to the published groups of other authors, the monitored group showed no difference in the mean age and gender ratio. There was an obvious increase in the number of patients with a low-energy mechanism of injury. The authors believe that this is the result of population ageing. It is also related to the growing share of patients treated non-operatively. The number of patients with a high-energy mechanism injury increased to a lesser degree. The spectrum of fractures significantly changed over the last 20 years. It was caused by an increase in low-energy injuries and partly also by improved diagnostics. CONCLUSIONS In the last 20 years, the authors noticed a rise in some types of acetabular fractures. It was caused by a statistically significantly higher number of fractures with a low-energy mechanism of injury, especially in elderly patients, the so-called "fragility fractures". Therefore, the share of non-operatively treated acetabular fractures increased as well. The number of acetabular fractures in young patients as a result of a high-energy injury grew more slowly, and it was only the share of posterior-wall acetabular fractures that was significantly higher. Key words: epidemiology of acetabular fractures, mechanism of injury, types of acetabular fractures.
- MeSH
- acetabulum diagnostické zobrazování zranění MeSH
- dítě MeSH
- dospělí MeSH
- fraktury kostí * diagnostické zobrazování epidemiologie chirurgie MeSH
- fraktury kyčle * diagnostické zobrazování epidemiologie chirurgie MeSH
- fraktury páteře * MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladiství MeSH
- mladý dospělý MeSH
- počítačová rentgenová tomografie MeSH
- rentgendiagnostika MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- Check Tag
- dítě MeSH
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladiství MeSH
- mladý dospělý MeSH
- mužské pohlaví MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
Intertrochanteric (IT) femur fractures are the most common fractures in elderly people, and they lead to significant morbidity, mortality, and reduced quality of life. The different types of fractures require a careful definition to ensure accurate surgical planning and reduce the operation time, healing time, and number of surgical failures. In this study, a deep learning-based automatic multi-class IT fracture detection model was developed using computed tomography (CT) images and based on the AO/OTA classification method. The original CT image was resized and rearranged according to the fracture location and an unsharp masking filter was applied. A multi-class classification of nine different types of IT fractures and no fracture was performed using the faster regional-convolutional neural network (R-CNN). Bayesian optimization was also implemented to determine the optimal hyperparameter values for the faster R-CNN algorithm. In our proposed model, IT fractures classified into two classes showed an average accuracy of 0.97 ± 0.02, which was 0.90 ± 0.02 when classified into ten classes. Additionally, the detected region of interest from our proposed model showed minimum root mean square error and intersection over union values of 16.34 ± 47.01 pixels and 0.87 ± 0.12, respectively. In the future, our proposed automatic multi-class IT femur fracture detection model could allow clinicians to identify the fracture region and diagnose different types of femur fractures faster and more accurately. This will increase the probability of correct surgical treatment and minimize postoperative complications.
- MeSH
- deep learning MeSH
- fraktury kyčle * diagnostické zobrazování klasifikace MeSH
- lidé MeSH
- neuronové sítě (počítačové) MeSH
- počítačová rentgenová tomografie * metody MeSH
- statistika jako téma MeSH
- Check Tag
- lidé MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- Publikační typ
- klinická studie MeSH
- práce podpořená grantem MeSH
