Anatomical Diversity in Femur bones: Understanding the Morphological Variability for Surgical and Prosthetic Applications / Diversidad Anatómica en Huesos Fémur: Comprensión de la Variabilidad Morfológica para Aplicaciones Quirúrgicas y Protésicas

SUMMARY: The femur, the body's longest bone, plays a critical role in orthopaedics and radiology. Understanding its anatomy, particularly the neck-shaft angle (NSA), is vital for diagnosing bone issues and designing hip implants. While some Asian populations' femur measurements have been studied, there is a research gap concerning Sri Lankans. This study aimed to fill this gap by examining the proximal femur's anatomy in the Sri Lankan population. We analysed 45 adult human femurs (26 right, 19 left) of unknown sex, ethically sourced from the University of Sri Jayewardenepura. Femurs with fractures or pathologies were excluded. Precise measurements were recorded using digital vernier callipers, with millimetre accuracy. Parameters included mean femoral length, vertical and transverse femoral head diameters, neck axis and neck length. Each measurement was taken three times to minimize subjectivity. Right femurs had a mean length of 42.8 mm (SD±2.64), while left femurs measured 43.53 mm (SD±3.27). Mean NSA was 125.78º (SD±4.45) for left femurs and 127.59º (SD±2.06) for right. Mean femoral head diameters were 4.09mm (SD±0.30) (right) and 4.12mm (SD±0.31) (left). Mean anterior neck lengths of the right and left were 2.61 (SD±0.54) and 2.71(SD±0.50) respectively. Comparing our findings with other Asian populations highlighted significant variations in femur measurements. These discrepancies emphasize the need for population-specific data for orthopaedic interventions and raise questions about the suitability of imported prosthetics. Differences in femur length, neck length, and NSA between sides suggest potential challenges in using implants designed for one side on the other. This study underscores the necessity of population-specific data in orthopaedics, as femur measurements differ even among Asian populations. Further research and statistical analysis are essential for tailoring orthopaedic solutions to individual populations. The findings also suggest a potential need for locally manufactured prosthetics to better suit the Sri Lankan population.

El fémur, el hueso más largo del cuerpo, desempeña un papel fundamental en ortopedia y radiología. Comprender su anatomía, en particular el ángulo cuello-diáfisis (NSA), es vital para diagnosticar problemas óseos y diseñar implantes de cadera. Si bien se han estudiado las medidas del fémur de algunas poblaciones asiáticas, existe un vacío en la investigación sobre los habitantes de Sri Lanka. Este estudio tuvo como objetivo examinar la anatomía del fémur proximal en la población de Sri Lanka. Analizamos 45 fémures humanos adultos (26 derechos, 19 izquierdos) de sexo desconocido, obtenidos éticamente de la Universidad de Sri Jayewardenepura. Se excluyeron fémures con fracturas o patologías. Se registraron mediciones precisas utilizando calibradores vernier digitales, con precisión milimétrica. Los parámetros incluyeron la longitud femoral media, los diámetros vertical y transversal de la cabeza femoral, el eje del cuello y la longitud del cuello. Cada medición se tomó tres veces para minimizar la subjetividad. Los fémures derechos tuvieron una longitud media de 42,8 mm (DE ± 2,64), mientras que los fémures izquierdos midieron 43,53 mm (DE ± 3,27). La NSA media fue de 125,78º (DE±4,45) para el fémur izquierdo y de 127,59º (DE±2,06) para el derecho. Los diámetros medios de la cabeza femoral fueron 4,09 mm (DE ± 0,30) (derecha) y 4,12 mm (DE ± 0,31) (izquierda). Las longitudes medias del cuello anterior de la derecha y la izquierda fueron 2,61 (DE ± 0,54) y 2,71 (DE ± 0,50) respectivamente. La comparación de nuestros hallazgos con otras poblaciones asiáticas destacó variaciones significativas en las medidas del fémur. Estas discrepancias enfatizan la necesidad de datos específicos de la población para las intervenciones ortopédicas y plantean dudas sobre la idoneidad de las prótesis importadas. Las diferencias en la longitud del fémur, la longitud del cuello y la NSA entre lados sugieren posibles desafíos al utilizar implantes diseñados para un lado en el otro. Este estudio subraya la necesidad de datos específicos de la población en ortopedia, ya que las mediciones del fémur difieren incluso entre las poblaciones asiáticas. Es esencial realizar más investigaciones y análisis estadísticos para adaptar las soluciones ortopédicas a poblaciones individuales. Los hallazgos también sugieren una posible necesidad de prótesis fabricadas localmente para adaptarse mejor a la población de Sri Lanka.

Análisis Morfológico y Biométrico de la Fóvea de la Cabeza del Fémur / Morphological and Biometric Analysis of the Fovea for Ligament of Head of Femur

En la literatura actual se encuentra escasa información referente a la fóvea de la cabeza del fémur (fóvea de la cabeza del hueso fémur). Este estudio tuvo como propósito recolectar datos morfológicos y biométricos respecto a la fóvea de la cabeza del fémur y reconocer variaciones que podrían ser de utilidad en las diversas patologías de la región. Se utilizaron 46 huesos fémures humanos pertenecientes al Departamento de Ciencias Básicas de la Universidad de La Frontera, Chile. Para la medición de datos se utilizó material ad hoc y los datos fueron analizados el programa Excel y los softwares ImageJ e Image Pro Plus. La longitud promedio de los huesos fémures fue de 43,8 ± 2,9 cm; el ángulo de torsión del cuello fue de 23,0 ± 2,0°. En el 100 % de las muestras se observó una fóvea en el cuadrante posteroinferior de la cabeza del fémur. El área promedio de la fóvea de la cabeza del fémur fue de 1,51 ± 0,7 cm2. El perímetro fue de 4,72 ± 1,0 cm; la forma de la fóvea fue: 60,9% ovalada, 23,9% triangular y 15,2 % circular, teniendo como base la fórmula derivada del índice craneal, dejando la fórmula como feret mínimo/feret máximo, con el cual los valores mayores a 0,8 se clasificaban como circulares y los menores como ovalados. Conocer la ubicación de la fóvea de la cabeza del fémur adquiere implicancia médica, ya que una fóvea en posición anormalmente alta, en imágenes radiológicas, es un indicador de displasia pélvica. La importancia de las variaciones de la fóvea de la cabeza del fémur debe ser más investigadas para una correcta comprensión de las patologías que afectan a la cabeza femoral.

SUMMARY: In the current literature there is little information regarding the fovea for ligament of head of femur. The aim of this study was to collect morphological and biometric data regarding the fovea for ligament of head of femur and recognize variations that could be useful in the various pathologies of the region. Forty six human femur bones belonging to the Department of Basic Sciences of the University of La Frontera, Chile were used. For data measurement, ad hoc material was used and the data were analyzed with the Excel program and the ImageJ and Image Pro Plus software. The average length of the femur bones was 43.8 ± 2.9 cm; the neck torsion angle was 23.0 ± 2.0°. In 100% of the samples, a fovea was observed in the posteroinferior quadrant of the head of femur. The average area of the fovea for ligament of head of femur was 1.51 ± 0.7 cm3. The perimeter was 4.72 ± 1.0 cm; The shape of the fovea was: 60.9% oval, 23.9% triangular and 15.2% circular, based on the formula derived from the cranial index, leaving the formula as minimum feret/maximum feret, with which the values greater than 0.8 were classified as circular and those less as oval. Knowing the location of the fovea for ligament of head of femur acquires medical implications, since a fovea in an abnormally high position, in radiological images, is an indicator of pelvic dysplasia. The importance of variations in the fovea for ligament of head of femur must be further investigated for a correct understanding of the pathologies that affect the femoral head.

Refixation of the Excised Acetabular Labrum can Affect the Structural Changes of Cartilage Surface in the Hip Joint / La Refijación del Labrum Acetabular Extirpado Puede Afectar los Cambios Estructurales de la Superficie del Cartílago en la Articulación Coxal

SUMMARY: Refixation of the damaged acetabular labrum is a method of surgical treatment of the hip joint that can promote the repair of joint function after injury and prevent premature osteoarthritis. We sought to determine the condition of the hip joint in rabbits 4 months after excision of the acetabular labrum and the condition of the joint after labral refixation. The articular cartilage of the femoral head and acetabulum was examined by histological methods, multipoint measurement of cartilage thickness, and the ratio between cartilage matrix and chondrocytes lacunae, and the condition of cartilage according to the OARSI grading scale was carried out. On this model, a correlation analysis was performed between the results of the OARSI grading scale and the data of linear morphometry. All these parameters made it possible to better assess changes in articular cartilage. The ratio between matrix and chondrocyte lacunae turned out to be a method that allows establishing early cartilage damage when erosion, fibrosis or deformation did not occur. We found significant differences between the condition of the cartilage after exicion of acetabular labrum and after labral refixation, which give hope to confirm that this surgical technique can delay or prevent progressive changes in the cartilage of the damaged hip joint.

La refijación del labrum acetabular dañado es un método de tratamiento quirúrgico de la articulación coxal, que puede promover la reparación de la función articular después de una lesión y prevenir la osteoartritis prematura. Intentamos determinar el estado de la articulación coxal en conejos de 4 meses después de la escisión del labrum acetabular y observar el estado de la articulación después de la refijación del labrum. El cartílago articular de la cabeza femoral y el acetábulo se examinó por métodos histológicos, se midió a través de multipunto el grosor del cartílago y se realizó la relación entre la matriz del cartílago y las lagunas de condrocitos, y se llevó a cabo la condición del cartílago según la escala de clasificación OARSI. Sobre este modelo se realizó un análisis de correlación entre los resultados de la escala de calificación OARSI y los datos de la morfometría lineal. Todos estos parámetros permitieron evaluar mejor los cambios en el cartílago articular. La relación entre la matriz y las lagunas de condrocitos resultó ser un método que permite establecer temprano el daño del cartílago cuando no se presentó erosión, fibrosis o deformación. Encontramos diferencias significativas entre la condición del cartílago después de la extirpación del labrum acetabular y después de la refijación del labrum, lo que da la esperanza de confirmar que esta técnica quirúrgica puede retrasar o prevenir cambios progresivos en el cartílago de la articulación coxal dañada.

Pipkin Type-II Femoral Head Fracture: A Biomechanical Evaluation by the Finite-Element Method / Fratura da cabeça femoral de tipo II de Pipkin: Avaliação biomecánica pelo método de elementos finitos

Abstract Objective To evaluate the biomechanical capacity of two forms of fixation for Pipkin type-II fractures, describing the vertical fracture deviation, the maximum and minimum principal stresses, and the Von Mises equivalent stress in the syntheses used. Materials and Methods Two internal fasteners were developed to treat Pipkin type-II fractures through finite elements: a 3.5-mm cortical screw and a Herbert screw. Under the same conditions, the vertical fracture deviation, the maximum and minimum principal stresses, and the Von Mises equivalent stress in the syntheses used were evaluated. Results The vertical displacements evaluated were of 1.5mm and 0.5mm. The maximum principal stress values obtained in the upper region of the femoral neck were of 9.7 KPa and 1.3 Kpa, and the minimum principal stress values obtained in the lower region of the femoral neck were of-8.7 KPa and -9.3 KPa. Finally, the peak values for Von Mises stress were of 7.2 GPa and 2.0 GPa for the fixation models with the use of the 3.5-mm cortical screw and the Herbert screw respectively. Conclusion The fixation system with the Herbert screw generated the best results in terms of reduction of vertical displacement, distribution of the maximum principal stress, and the peak Von Mises equivalent stress, demonstrating mechanical superiority compared to that of the 3.5-mm cortical screw in the treatment of Pipkin type-II fractures.

Resumo Objetivo Avaliar a capacidade biomecánica de duas formas de fixação de fraturas tipo II de Pipkin descrevendo o desvio da fratura no sentido vertical, as tensões máxima e mínima principais, e a tensão equivalente de Von Mises nas sínteses utilizadas. Materiais e Métodos Dois fixadores internos foram desenvolvidos para tratar a fratura tipo II de Pipkin por meio de elementos finitos: parafuso cortical de 3,5 mm e parafuso de Herbert. Sob as mesmas condições, foram avaliados o desvio da fratura no sentido vertical, as tensões máxima e mínima principais, e a tensão equivalente de Von Mises nas sínteses utilizadas. Resultados Os deslocamentos verticais avaliados foram de 1,5 mm e 0,5 mm. Os valores de tensão máxima obtidos na região superior do colo femoral foram de 9,7 KPa e 1,3 KPa, e os valores de tensão mínima obtidos na região inferior do colo femoral foram de -8,7KPa e -9,3 KPa. Por fim, os valores de pico da tensão equivalente de Von Misesforam de 7,2 GPa e2,0 GPa paraosmodelos de fixação com o uso do parafuso cortical de 3,5 mm e do parafuso de Herbert, respectivamente. Conclusão Osistema de fixação com parafuso de Herbert gerou os melhores resultados em termos de redução do deslocamento vertical, distribuição da tensão máxima e do pico da tensão equivalente de Von Mises, o que demonstra sua superioridade mecânica comparada à do parafuso cortical de 3,5 mm no tratamento da fratura tipo II de Pipkin.

Primary repair for concurrent bilateral intertrochanteric fracture and femoral head necrosis with prolonged shank biologic total hip replacement: A case report and surgical techniques / 中华创伤杂志(英文版)

For the treatment of an intertrochanteric fracture combined with femoral head necrosis in middle-age patients, it has been controversial whether to perform fracture reduction and fixation first then total hip replacement, or direct total hip replacement. We present a rare case of 53-year-old male patient suffered from bilateral intertrochanteric fracture caused by a road traffic injury. The patient had a history of femoral head necrosis for eight years, and the Harris score was 30. We performed total hip replacement with prolonged biologic shank prostheses for primary repair. One year after the surgery, nearly full range of motion was achieved without instability (active flexion angle of 110°, extension angle of 20°, adduction angle of 40°, abduction angle of 40°, internal rotation angle of 25°, and external rotation angle of 40°). The Harris score was 85. For the middle-aged patient with unstable intertrochanteric fractures and osteonecrosis of the femoral head, we can choose primary repair for concurrent bilateral intertrochanteric fracture and femoral head necrosis with prolonged shank biologic total hip replacement.

Visual and quantitative assessment of the effectiveness of non-vascularized bone grafting in osteonecrosis of the femoral head via CT-based radiomics and clinical data / 中国修复重建外科杂志

OBJECTIVE@#To investigate the value of CT-based radiomics and clinical data in predicting the efficacy of non-vascularized bone grafting (NVBG) in hip preservation, and to construct a visual, quantifiable, and effective method for decision-making of hip preservation.@*METHODS@#Between June 2009 and June 2019, 153 patients (182 hips) with osteonecrosis of the femoral head (ONFH) who underwent NVBG for hip preservation were included, and the training and testing sets were divided in a 7∶3 ratio to define hip preservation success or failure according to the 3-year postoperative follow-up. The radiomic features of the region of interest in the CT images were extracted, and the radiomics-scores were calculated by the linear weighting and coefficients of the radiomic features after dimensionality reduction. The clinical predictors were screened using univariate and multivariate Cox regression analysis. The radiomics model, clinical model, and clinical-radiomics (C-R) model were constructed respectively. Their predictive performance for the efficacy of hip preservation was compared in the training and testing sets, with evaluation indexes including area under the curve, C-Index, sensitivity, specificity, and calibration curve, etc. The best model was visualised using nomogram, and its clinical utility was assessed by decision curves.@*RESULTS@#At the 3-year postoperative follow-up, the cumulative survival rate of hip preservation was 70.33%. Continued exposure to risk factors postoperative and Japanese Investigation Committee (JIC) staging were clinical predictors of the efficacy of hip preservation, and 13 radiomic features derived from least absolute shrinkage and selection operator downscaling were used to calculate Rad-scores. The C-R model outperformed both the clinical and radiomics models in predicting the efficacy of hip preservation 1, 2, 3 years postoperative in both the training and testing sets ( P<0.05), with good agreement between the predicted and observed values. A nomogram constructed based on the C-R model showed that patients with lower Rad-scores, no further postoperative exposure to risk factors, and B or C1 types of JIC staging had a higher probability of femoral survival at 1, 2, 3 years postoperatively. The decision curve analysis showed that the C-R model had a higher total net benefit than both the clinical and radiomics models with a single predictor, and it could bring more net benefit to patients within a larger probability threshold.@*CONCLUSION@#The prediction model and nomogram constructed by CT-based radiomics combined with clinical data is a visual, quantifiable, and effective method for decision-making of hip preservation, which can predict the efficacy of NVBG before surgery and has a high value of clinical application.

Biomechanical effects of three internal fixation modes on femoral subtrochanteric spiral fractures in osteoporotic patients by finite element analysis / 中国修复重建外科杂志

OBJECTIVE@#The biomechanical characteristics of three internal fixation modes for femoral subtrochanteric spiral fracture in osteoporotic patients were compared and analyzed by finite element technology, so as to provide the basis for the optimization of fixation methods for femoral subtrochanteric spiral fracture.@*METHODS@#Ten female patients with osteoporosis and femoral subtrochanteric spiral fractures caused by trauma, aged 65-75 years old, with a height of 160-170 cm and a body weight mass of 60-70 kg, were selected as the study subjects. The femur was scanned by spiral CT and a three-dimensional model of the femur was established by digital technology. The computer aided design models of proximal intramedullary nail (PFN), proximal femoral locking plate (PFLP), and the combination of the two (PFLP+PFN) were constructed under the condition of subtrochanteric fracture. Then the same load of 500 N was applied to the femoral head, and the stress distribution of the internal fixators, the stress distribution of the femur, and the displacement of femur after fracture fixation were compared and analyzed under the three finite element internal fixation modes, so as to evaluate the fixation effect.@*RESULTS@#In the PFLP fixation mode, the stress of the plate was mainly concentrated in the main screw channel, the stresses of the different part of the plate were not equal, and gradually decreased from the head to the tail. In the PFN fixation mode, the stress was concentrated in the upper part of the lateral middle segment. In the PFLP+PFN fixation mode, the maximum stress appeared between the first and the second screws in the lower segment, and the maximum stress appeared in the lateral part of the middle segment of the PFN. The maximum stress of PFLP+PFN fixation mode was significantly higher than that of PFLP fixation mode, but significantly lower than that of PFN fixation mode ( P<0.05). In PFLP and PFN fixation modes, the maximum stress of femur appeared in the medial and lateral cortical bone of the middle femur and the lower side of the lowest screw. In PFLP+PFN fixation mode, the stress of femur concentrated in the medial and lateral of the middle femur. There was no significant difference in the maximum stress of femur among the three finite element fixation modes ( P>0.05). The maximum displacement occurred at the femoral head after three finite element fixation modes were used to fix subtrochanteric femoral fractures. The maximum displacement of femur in PFLP fixation mode was the largest, followed by PFN, and PFLP+PFN was the minimum, with significant differences ( P<0.05).@*CONCLUSION@#Under static loading conditions, the PFLP+PFN fixation mode produces the smallest maximum displacement when compared with the single PFN and PFLP fixation modes, but its maximum plate stress is greater than the single PFN and PFLP fixation mode, suggesting that the combination mode has higher stability, but the plate load is greater, and the possibility of fixation failure is higher.

Analysis of incidence and clinical characteristics of osteonecrosis of femoral head in patients with systemic lupus erythematosus treated with glucocorticoid: A descriptive study based on a prospective cohort / 中国修复重建外科杂志

OBJECTIVE@#To describe the disease characteristics of osteonecrosis of the femoral head (ONFH) in patients with systemic lupus erythematosus (SLE) who experiencing prolonged glucocorticoid (GC) exposure.@*METHODS@#Between January 2016 and June 2019, 449 SLE patients meeting the criteria were recruited from multiple centers. Hip MRI examinations were performed during screening and regular follow-up to determine the occurrence of ONFH. The cohort was divided into ONFH and non-ONFH groups, and the differences in demographic baseline characteristics, general clinical characteristics, GC medication information, combined medication, and hip clinical features were compared and comprehensively described.@*RESULTS@#The age at SLE diagnosis was 29.8 (23.2, 40.9) years, with 93.1% (418 cases) being female. The duration of GC exposure was 5.3 (2.0, 10.5) years, and the cumulative incidence of SLE-ONFH was 9.1%. Significant differences ( P<0.05) between ONFH and non-ONFH groups were observed in the following clinical characteristics: ① Demographic baseline characteristics: ONFH group had a higher proportion of patients with body mass index (BMI)<20 kg/m 2 compared to non-ONFH group. ② General clinical characteristics: ONFH group showed a higher proportion of patients with cutaneous and renal manifestations, positive antiphospholipid antibodies (aPLs) and anticardiolipin antibodies, severe SLE patients [baseline SLE Disease Activity Index 2000 (SLEDAI-2K) score ≥15], and secondary hypertension. Fasting blood glucose in ONFH group was also higher. ③ GC medication information: ONFH group had higher initial intravenous GC exposure rates, duration, cumulative doses, higher cumulative GC doses in the first month and the first 3 months, higher average daily doses in the first 3 months, and higher proportions of average daily doses ≥15.0 mg/d and ≥30.0 mg/d, as well as higher full-course average daily doses and proportion of full-course daily doses ≥30.0 mg/d compared to non-ONFH group. ④ Combined medications: ONFH group had a significantly higher rate of antiplatelet drug use than non-ONFH group. ⑤ Hip clinical features: ONFH group had a higher proportion of hip discomfort or pain and a higher incidence of hip joint effusion before MRI screening than non-ONFH group.@*CONCLUSION@#The incidence of ONFH after GC exposure in China's SLE population remains high (9.1%), with short-term (first 3 months), medium-to-high dose (average daily dose ≥15 mg/d) GC being closely associated with ONFH. Severe SLE, low BMI, certain clinical phenotypes, positive aPLs, and secondary hypertension may also be related to ONFH.

A novel lateral classification of osteonecrosis of femoral head based on CT recons-truction of necrotic area and its clinical verification / 中国修复重建外科杂志

OBJECTIVE@#To analyze the femoral head collapse and the operation of osteonecrosis of the femoral head (ONFH) in different Japanese Investigation Commitee (JIC) types, in order to summarize the prognostic rules of each type of ONFH, and explore the clinical significance of CT lateral subtypes based on reconstruction of necrotic area of C1 type and verify their clinical effect.@*METHODS@#A total of 119 patients (155 hips) with ONFH between May 2004 and December 2016 were enrolled in the study. The total hips consisted of 34 hips in type A, 33 in type B, 57 in type C1, and 31 in type C2, respectively. There was no significant difference in age, gender, affected side, or type of ONFH of the patients with differenct JIC types ( P>0.05). The 1-, 2-, and 5-year femoral head collapse and operation of different JIC types were analyzed, as well as the survival rate (with femoral head collapse as the end point) of hip joint between different JIC types, hormonal/non-hormonal ONFH, asymptomatic and symptomatic (pain duration >6 months or ≤6 months), and combined preserved angle (CPA) ≥118.725° and CPA<118.725°. JIC types with significant differences in subgroup surgery and collapse and with research value were selected. According to the location of the necrotic area on the surface of the femoral head, the JIC classification was divided into 5 subtypes in the lateral CT reconstruction, and the contour line of the necrotic area was extracted and matched to the standard femoral head model, and the necrosis of the five subtypes was presented by thermography. The 1-, 2-, and 5-year outcomes of femoral head collapse and operation in different lateral subtypes were analyzed, and the survival rates (with collapse of the femoral head as the end point) between CPA≥118.725° and CPA<118.725° hip in patients with this subtype were compared, as well as the survival rates of different lateral subtypes (with collapse and surgery as the end points, respectively).@*RESULTS@#The femoral head collapse rate and operation rate in the 1-, 2-, and 5-year were significantly higher in patients with JIC C2 type than in patients with other hip types ( P<0.05), while in patients with JIC C1 type than in patients with JIC types A and B ( P<0.05). The survival rate of patients with different JIC types was significantly different ( P<0.05), and the survival rate of patients with JIC types A, B, C1, and C2 decreased gradually. The survival rate of asymptomatic hip was significantly higher than that of symptomatic hip, and the survival rate of CPA≥118.725° was significantly higher than that of CPA<118.725° ( P<0.05). The lateral CT reconstruction of type C1 hip necrosis area was selected for further classification, including type 1 in 12 hips, type 2 in 20 hips, type 3 in 9 hips, type 4 in 9 hips, and type 5 in 7 hips. There were significant differences in the femoral head collapse rate and the operation rate among the subtypes after 5 years of follow-up ( P<0.05). The collapse rate and operation rate of types 4 and 5 were 0; the collapse rate and operation rate of type 3 were the highest; the collapse rate of type 2 was high, but the operation rate was lower than that of type 3; the collapse rate of type 1 was high, but the operation rate was 0. In JIC type C1 patients, the survival rate of the hip joint with CPA≥118.725° was significantly higher than that with CPA<118.725° ( P<0.05). In the follow-up with femoral head collapse as the end point, the survival rates of types 4 and 5 were all 100%, while the survival rates of types 1, 2, and 3 were all 0, and the difference was significant ( P<0.05). The survival rate of types 1, 4, and 5 was 100%, of type 3 was 0, and of type 2 was 60%, showing significant difference ( P<0.05).@*CONCLUSION@#JIC types A and B can be treated by non-surgical treatment, while type C2 can be treated by surgical treatment with hip preservation. Type C1 was classified into 5 subtypes by CT lateral classification, type 3 has the highest risk of femoral head collapse, types 4 and 5 have low risk of femoral head collapse and operation, type 1 has high femoral head collapse rate but low risk of operation; type 2 has high collapse rate, but the operation rate is close to the average of JIC type C1, which still needs to be further studied.

Assessment of the local blood supply when femoral neck fracture occurs:advances in the anatomy research and its clinical application / 中国骨伤

The stability of internal fixation of femoral neck fractures can be obtained through surgical techniques, the configuration of screws and bone grafting, etc. However, the blood supply injury caused by fractures could not be completely reversed by the current medical management. Hence, the comprehensive evaluation of the residual blood supply of the femoral neck, to perioperatively avoid further iatrogenic injury, has become a hotspot. The anatomy of the extraosseous blood supply of the femoral neck has been widely reported, while its clinical application mostly involved the assessment of the medial circumflex femoral artery and retinacular arteries. However, further studies are needed to explore the prognosis of patients with these artery injuries, with different degrees, caused by femoral neck fractures. Direct observations of nutrient foramina in vivo are not possible with current clinical technologies, but it is possible to make reasonable preoperative planning to avoid subsequent femoral head necrosis based on the distribution features of nutrient foramina. The anatomy and clinical application studies of the intraosseous blood supply focused on the junction area of the femoral head and neck to probe the mechanism of femoral head necrosis. Thus, the intraosseous blood supply of other regions in the femoral neck remains to be further investigated. In addition, a blood supply evaluation system based on a three-level structure, extraosseous blood vessels, nutrient foramina, and intraosseous vascular network, could be explored to assist in the treatment of femoral neck fractures.

Clinical study on core decompression in treating osteonecrosis of the femoral head of the necrotic bone-in different site / 中国骨伤

OBJECTIVE@#To analyze the clinical effect of decompression and bone grafting on osteonecrosis of the femoral head(ONFH) at different sites of necrotic lesions.@*METHODS@#A total of 105 patients with ARCOⅡstage ONFH admitted from January 2017 to December 2018 were retrospectively analyzed. There were 71 males and 34 females, with an average age of (55.20±10.98) years old. The mean course of all patients was(15.91±9.85) months. According to Japanese Inveatigation Committee (JIC) classification, all patients were divided into 4 types:17 cases of type A, 26 cases of type B, 33 cases of type C1 and 29 cases of type C2. All four groups were treated with decompression of the pulp core and bone grafting. Visual analogue scale(VAS) and Harris hip joint score were used before and at 3, 6, 12, and 24 months after the operation, and the collapse of the femoral head was observed by X-ray examination within 2 years.@*RESULTS@#All 105 patients were successful on operation without complications, and the mean follow-up duration was (24.45±2.75) months. Harris score showed that there was no statistical difference among four groups before surgery and 3, 6 months after surgery (P>0.05);at 12 and 24 months after surgery, there were significant differences among all groups (P<0.01). There were significant differences in intragroup Harris scores at preoperative and postoperative time points among four groups (P<0.01). VAS showed that there was no statistical difference among four groups before and 3, 6 months after surgery (P>0.05);at 12 and 24 months after surgery, there were significant differences among all groups (P<0.01). There were significant differences in VAS at preoperative and postoperative time points among four groups (P<0.01). None of the patients in four groups had femoral head collapse before and 3, 6 months after surgery. At 12 months after operation, there were 3 cases of femoral head collapse in group C and 4 cases in group C2(P>0.05);At 24 months after operation, 1 case of femoral head collapse occurred in group B, 6 cases in group C1 and 8 cases in group C2(P<0.05).@*CONCLUSION@#Core decompression and bone grafting can improve the effect of ONFH and hip preservation. The effect of hip preservation for ONFH is closely related to the location of the osteonecrosis lesion, so the influence of the location of lesion on the effect of hip preservation should be considered in clinical treatment, so as to make better preoperative hip preservation plan.

Imaging measurement and analysis of related indexes of variation of femoral head rotation center / 中国骨伤

OBJECTIVE@#To provide guidance for hip replacement by analyzing the variation of femoral head rotation center in different hip diseases.@*METHODS@#A total of 5 459 patients were collected from March 2016 to June 2021, who took positive and proportional plain films of both hips for various reasons. The relative position between the rotation center of the femoral head and the apex of the greater trochanter was measured. The positive variation is more than 2 mm above the top of the great trochanter, and the negative variation is more than 2 mm below the top of the great trochanter. A total of 831 patients with variation of femoral head rotation center were collected and were divided into 4 groups according to different diseases, and the variation was counted respectively. There were 15 cases in the normal group involving 10 cases of positive variation and 5 cases of negative variation. There were 145 cases of avascular necrosis of femoral head involving 25 cases of positive variation and 120 cases of negative variation. There were 346 cases of congenital hip dysplasia involving 225 cases of positive variation(including 25 cases of typeⅠ, 70 cases of type Ⅱ, 115 cases of type Ⅲ and 15 cases of type Ⅳ), and 121 cases of negative variation(including 50 cases of crowe typeⅠ, 60 cases of typeⅡ, 10 cases of type Ⅲ and 1 case of type Ⅳ). There were 325 cases of hip osteoarthritis group involving 45 cases of positive variation and 280 cases of negative variation.@*RESULTS@#There was significant difference in variation of femoral head rotation center among the four groups(P<0.05). There was significant difference in variation of femoral head rotation center among different types of congenital hip dysplasia(P<0.05). There were significant differences in cervical trunk angle and eccentricity among different variations of femoral head rotation center(P<0.05).@*CONCLUSION@#The variation of femoral head rotation center is related to cervical trunk angle and eccentricity. The variation of femoral head rotation center is an important factor in hip diseases. The variation of femoral head rotation center is different in different hip diseases. Avascular necrosis of the femoral head and osteoarthritis of the hip were mostly negative variations. With the aggravation of congenital hip dysplasia, the variation of femoral head rotation center gradually changed from negative variation to positive variation.The variation of femoral head rotation center should be paid attention to in the preoperative planning of hip arthroplasty. It is of great significance to select the appropriate prosthesis and place the prosthesis accurately.

Disastrous triad of femoral head:femoral neck fracture meeting fracture-dislocation of femoral head / 中国骨伤

Femoral head and ipsilateral femoral neck fractures are serious and complicated injuries, which usually yield unsatisfactory results using conventional hip-preserving surgery. The key point of the management and prognosis mainly lies in femoral neck fractures. An apparent and consecutive relationship exists between femoral neck fractures and femoral head fracture-hip dislocation in such injuries. It is believed that disastrous triad of femoral head (DTFH) could summarize these specific injuries, and reflect the injury mechanism and prognostic characteristics. Based on our clinical observation and literature review, DTFH could be divided into three subgroups:TypeⅠ, common DTFH, in which femoral neck fractures occur following femoral head fractures-hip dislocation due to the same trauma; TypeⅡ, iatrogenic DTFH, in which femoral neck fractures come out in the caring process of femoral head fractures-hip dislocation; Type Ⅲ, stressed DTFH, in which femoral neck fractures occur after the management of femoral head fractures-hip dislocation. In the scenario, the line of femoral neck fractures locates distally to the femoral head fractures. Herein, we will discuss clinical characteristics of these types of DTFH.

Evaluation and treatment strategy of limb length discrepancy after total hip arthroplasty / 中华外科杂志

Limb length discrepancy(LLD) is a common complication after total hip arthroplasty (THA). Good positioning of the prosthesis and suitable soft tissue tension are essential to ensure hip joint stability. Patients will be more satisfied if almost the same length of both lower extremities is achieved. Preoperative comprehensive evaluation of patients is helpful to prevent the occurrence of LLD after surgery. Therefore, the pelvic spine conditions, as well as type and cause of LLD should be analyzed in detail before surgery. During operation, limb length should be adjusted by touching the position of patella, Kirschner's wires positioning and referring to the relationship between the center of femoral head and the tip of greater trochanter. After surgery, it is necessary to clearly distinguish true LLD from functional LLD, and make a reasonable therapeutic plan according to patient's symptoms and the range of differences in limb length. This article reviews the latest literatures based on clinical practice experience and summarizes the research status of LLD after THA, which helps joint surgeons to have an in-depth understanding of this postoperative complication.

Epiphysiolysis in a 22-year-old Patient with Congenital Hypogonadotropic Hypogonadism: Case Report / Epifisiólise em paciente de 22 anos de idade com hipogonadismo hipogonadotrópico congênito: Relato de caso

Abstract Epiphysiolysis is a relatively common disease in the adolescent population (9-16 years); however, it is rare in the adult population. It is characterized by non-traumatic proximal femur slipping. When it occurs in this population it is associated with some disease that slows sexual development and physis closure, such as endocrine diseases or brain tumors. The aim of the present study is to report a case of epiphysiolysis in a 22-year-old patient with hypogonadotropic hypogonadism. There are only 63 cases reported in the world literature on epiphysiolysis in the adult population.

Resumo A epifisiólise é uma doença relativamente comum na população adolescente (de 9-16 anos), entretanto rara na população adulta. Se caracteriza pelo escorregamento metáfiso-epifisário do fêmur proximal não-traumático. Quando ocorre nessa população, está associada a alguma doença que retarda o desenvolvimento sexual e fechamento fisário, como doenças endocrinológicas ou tumores cerebrais. O objetivo do presente estudo é relatar um caso de epifisiólise numa paciente com 22 anos de idade e hipogonadismo hipogonadotrófico. Existem apenas 63 casos relatados na literatura mundial sobre epifisiólise na população adulta.

Effectiveness of platelet-rich plasma as an adjunct to core decompression to treatment outcomes and femoral head preservation in avascular necrosis of the hip: A meta-analysis of randomized controlled trials

Background@#Avascular necrosis (AVN) of the femoral head results from intraosseous pathology causing functional impairment. Early diagnosis allows conservative treatment like core decompression, delaying total hip arthroplasty.@*Objective@#This meta-analysis aims to summarize platelet-rich plasma's (PRP) impact as an adjunct to core decompression (CD) on treatment outcomes and femoral head preservation in hip AVN. @*Methods@#The study conducted a comprehensive literature search using PubMed, Cochrane Library, Science Direct, Google Scholar and Med Line, including randomized controlled trials (RCTs) and previous meta-analyses from various databases. Using a random effects model, it compared PRP+CD with bone grafting to CD with bone grafting alone in AVN patients, evaluating function, pain scores, disease progression and the need for hip surgery.@*Results@#The meta-analysis examined 1041 records and included three studies. The primary outcomes were function and pain scores using Harris Hip Scoring (HHS) and Visual Analog Scale (VAS). Postoperative HHS scores at final follow-up favored the PRP+CD group significantly over CD alone. Postoperative VAS scores showed a trend towards higher scores in the CD alone group. The PRP+CD group demonstrated higher survival from disease progression compared to CD alone. Overall, the study suggests that PRP+CD led to better functional outcomes and disease progression outcomes than CD alone in AVN of the hip.@*Conclusion@#The PRP+CD treatment group showed significant benefits in AVN patients compared to CD alone, including higher HHS scores, improved disease progression survival and reduced need for hip surgery. Although PRP+CD resulted in decreased VAS scores, the difference was not statistically significant.

Anatomical features of the proximal femur in the Turkish population / Características anatómicas del fémur proximal en la población turca

SUMMARY: Different populations have different genetic traits, and this causes various anatomical features to emerge. Orthopedic implants used in Turkey are generally of Western origin, and these implants are designed based on the anatomical features of Western populations. This study aimed to evaluate the compatibility of existing implants for the Turkish population by revealing the anatomical features of the proximal femurs of individuals from the Turkish population while also constituting a helpful source of data on newly developed implants. A total of 1920 proximal femurs of 960 patients were evaluated via images obtained by Computer Tomography. Twenty patients (10 females and 10 males) for each age within the age range of 18-65 years were included. Femoral head diameter, femoral neck width, femoral neck length, medullary canal width, and collodiaphyseal angle were measured. The right and left femoral head diameter was 46.46±3.84 mm, 46.50 ±3.85 mm respectively. The right and left femoral neck width was 30.63±3.4 mm, 30.85±3.29 mm respectively. The neck length was 94.62±8.33 mm for the right proximal femur, it was 94.75±8.19 mm for the left. The width of the medullary canal was 15.46±2.25 mm for the right proximal femur and 15.53±2.20 mm for the left. The right and left hips, the collodiaphyseal angles were 133.06±2.39° and 133.13±2.36°. Anatomical features of the proximal femur vary according to age, sex, and race. This study may be used as an important resource for the evaluation of patients' compatibility with existing implants and for the design of new implants.

Diferentes poblaciones tienen diferentes rasgos genéticos, y esto hace que surjan varias características anatómicas. Los implantes ortopédicos utilizados en Turquía son generalmente de origen occidental y estos implantes están diseñados en función de las características anatómicas de estas poblaciones. Este estudio tuvo como objetivo evaluar la compatibilidad de los implantes existentes para la población turca al revelar las características anatómicas de las epífisis proximales de fémures de individuos de la población turca y, al mismo tiempo, constituir una fuente útil de datos sobre implantes recientemente desarrollados. Se evaluaron un total de 1920 fémures proximales de 960 pacientes mediante imágenes obtenidas por tomografía computarizada. Se incluyeron veinte pacientes (10 mujeres y 10 hombres) para cada edad dentro del rango de edad de 18 a 65 años. Se midió el diámetro de la cabeza femoral, el ancho del cuello femoral, la longitud del cuello femoral, el ancho del canal medular y el ángulo colodiafisario. El diámetro de la cabeza femoral derecha e izquierda fue de 46,46 ± 3,84 mm, 46,50 ± 3,85 mm, respectivamente. La anchura del cuello femoral derecho e izquierdo fue de 30,63±3,4 mm, 30,85±3,29 mm, respectivamente. La longitud del cuello fue de 94,62±8,33 mm para el fémur derecho, fue de 94,75±8,19 mm, para el izquierdo. El ancho del canal medular fue de 15,46±2,25 mm para el fémur derecho y de 15,53±2,20 mm para el izquierdo. Las caderas derecha e izquierda, los ángulos colodiafisarios fueron 133,06±2,39° y 133,13±2,36°. Las características anatómicas de la epífisis proximal del fémur varían según la edad, el sexo y la raza. Este estudio puede utilizarse como un recurso importante para la evaluación de la compatibilidad de los pacientes con los implantes existentes y para el diseño de nuevos implantes.

Osteonecrosis of the Femoral Head: Update Article / Osteonecrose da cabeça femoral: Artigo de atualização

Abstract Among the pathologies that affect the hip joint, osteonecrosis of the femoral head (ONFH) is probably the most intriguing and challenging. It consists of a multifactorial disease with a highly-variable spectrum in its clinical presentation. It has a devastating effect, due to disabling painful conditions, both for usual activities and sports. Given the huge range of risk factors, such as prolonged use of corticosteroids (especially in cases of rheumatologic diseases), trauma sequelae, sickle cell anemia, HIV, alcoholism, smoking, blood dyscrasias, and several other diseases that compromise the blood supply to the femoral head, ONFH has a varied clinical presentation and prognosis, which makes it difficult to determine a specific treatment, especially in cases in which chondral involvement has not yet occurred and the hip joint is still preserved. These are the main factors found in the literature that determine the classifications of this pathology. The range of treatments includes several options for cases in which an attempt is made to save the joint: conservative treatment, traditional decompression and/or combined with some type of adjuvant treatment (homologous grafting, synthetic grafting, vascularized grafts, tantalum screws, and bone marrow aspirate injection), and, for cases in which there is already a subchondral fracture and/or collapse of the femoral head and/or a reduction in the joint space, femoral osteotomies or total hip arthroplasty are commonly performed.

Resumo Entre as patologias que acometem a articulação coxofemoral, a osteonecrose da cabeça femoral (ONCF) é provavelmente a mais intrigante e desafiadora. Consiste em uma doença multifatorial, com um espectro muito variável em sua apresentação clínica. Tem efeito devastador, devido a quadros dolorosos incapacitantes tanto para atividades habituais quanto esportivas. Dada a gama enorme de fatores de risco, tais como uso prolongado de corticoides (principalmente em casos de doenças reumatológicas), sequelas de trauma, anemia falciforme, HIV, etilismo, tabagismo, discrasias sanguíneas, e várias outras doenças que comprometem a irrigação sanguínea da cabeça femoral, a ONCF tem apresentação clínica e prognósticos bem variados, o que dificulta a determinação de um tratamento específico, especialmente em casos nos quais ainda não houve acometimento condral e a articulação do quadril ainda se mantém preservada, sendo estes os principais fatores encontrados na literatura que determinam as classificações desta patologia. No leque de tratamentos, encontramos diversas opções para os casos em que setenta salvar a articulação: tratamento conservador, descompressão simples e/ou associada a algum tipo de tratamento adjuvante (enxertia homóloga, enxertia sintética, enxertos vascularizados, parafusos de tântalo, e injeção de aspirado de medula óssea), e, para casos nos quais já há fratura subcondral e/ou colapso da cabeça femoral e/ou diminuição do espaço articular, reserva-se, comumente, a realização de osteotomias femorais ou artroplastia total do quadril.

Case-control study on robot-assisted core decompression and conventional core decompression for early necrosis of femoral head / 中国骨伤

OBJECTIVE@#To compare clinical effect of robot-assisted core decompression and conventional core decompression in treating ARCO Ⅰ stage necrosis of femoral head.@*METHODS@#A retrospective analysis was performed on 60(unilateral operation) patients who underwent core decompression for femoral head necrosis from February 2018 to February 2020. Among them, 30 patients(30 hips) were underwent robot-assisted core decompression (RCD group), including 19 males and 11 females, aged from 17 to 58 years old with an average of(38.50±10.61) years old;30 patients(30 hips) were underwent traditional core decompression surgery (CCD group), including 20 males and 10 females, aged from 20 to 55 years old with an average of (40.63±10.63) years old. Intraoperative fluoroscopy times, intraoperative blood loss and operation time between two groups, and Harris score, visual analogue scale (VAS) before opertaion and 24 months after operation were compared.@*RESULTS@#All patients were followed up, RCD group followed up from 21 to 26 months with an average of(23.40±1.65) months, CCD group followed up from 21 to 26 months with an average of (23.30±1.66) months, and had no difference between two groups(P>0.05). The number of intraoperative X-ray fluoroscopy, intraoperative blood loss and operative time in RCD group were (9.43±1.14) times, (153.80±22.04) ml, (33.40±1.87) min, respectively;while(19.67±1.32) times, (165.04±20.41) ml and (54.75±3.46) min in CCD group respectively;and there were statistical difference between two groups(P<0.05). In addition, there were no statistical difference between two groups in Harris score and VAS at 24 months after operation(P>0.05).@*CONCLUSION@#Compared with conventional core decompression, robot-assisted core decompression could reduce the number of intraoperative fluoroscopy, shorten operation time, and reduce risk of surgery.

Femoral head necrosis rate and risk factors after internal fixation of femoral neck fracture:a Meta-analysis / 中国骨伤

OBJECTIVE@#To study the incidence and risk factors of osteonecrosis of the femoral head (ONFH) after internal fixation in adult patients with femoral neck fracture (FNF) after 2000, and identify high-risk population of ONFH.@*METHODS@#PubMed, Medline, The Cochrane Library, CNKI, Wanfang and VIP Database were searched to collect all the literatures on ONFH and related risk factors after internal fixation of FNF from January 1th 2000 to July 1th 2020. Study extraction was performed according to inclusion and exclusion criteria. Endnote X9 and Excel 2019 were used for literatures extraction, management and data entry, and R Studio 3.6.5 software was used for Meta-analysis. Subgroup analysis, sensitivity analysis and publication bias detection were used to explore the sources of heterogeneity and the reliability of the evaluation results.@*RESULTS@#A total of 16 studies with 5521 patients were included. Meta-analysis showed that the incidence of ONFH after internal fixation for adult FNF was 14.5% [95% CI(0.126-0.165)]. Fracture displacement[OR=0.27, 95%CI(0.21-0.35)] and reduction quality [OR=0.15, 95%CI(0.09-0.27)] were related risk factors for ONFH. The results of subgroup rate analysis showed that the non-displaced fracture necrosis rate was 6.2%[95%CI(0.051-0.077)] and the displaced fracture necrosis rate was 20.4% [95%CI(0.166-0.249)];the good reduction fracture necrosis rate was 8.3%[95%CI(0.072-0.095)] and the poor reduction fracture necrosis rate was 35.5%[95%CI(0.233-0.500)]. The included literatures have good consistency and no publication bias.@*CONCLUSION@#After 2000, the total incidence of ONFH after internal fixation of adult FNF has decreased, while the necrosis rates of patients with displaced fracture and poor reduction are still at a high level. The interval between injury and surgery was not analyzed in this study because of the inconstant division in the original literature.