Evaluation of Singh index for assessment of osteoporosis using digital radiography

Automated osteoporosis classification and T-score prediction using hip radiographs via deep learning algorithm

Background

Despite being the gold standard for diagnosing osteoporosis, dual-energy X-ray absorptiometry (DXA) is an underutilized screening tool for osteoporosis.

Objectives

This study proposed and validated a controllable feature layer of a convolutional neural network (CNN) model with a preprocessing image algorithm to classify osteoporosis and predict T-score on the proximal hip region via simple hip radiographs.

Design

This was a single-center, retrospective study.

Methods

An image dataset of 3460 unilateral hip images from 1730 patients (age ⩾50 years) was retrospectively collected with matched DXA assessment for T-score for the targeted proximal hip regions to train (2473 unilateral hip images from 1430 patients) and test (497 unilateral hip images from 300 patients) the proposed CNN model. All images were processed with a fully automated CNN model, X1AI-Osteo.

Results

The proposed screening tool illustrated a better performance (sensitivity: 97.2%; specificity: 95.6%; positive predictive value: 95.7%; negative predictive value: 97.1%; area under the curve: 0.96) than the open-sourced CNN models in predicting osteoporosis. Moreover, when combining variables, including age, body mass index, and sex as features in the training metric, there was high consistency in the T-score on the targeted hip regions between the proposed CNN model and the DXA (r = 0.996, p < 0.001).

Conclusion

The proposed CNN model may identify osteoporosis and predict T-scores on the targeted hip regions from simple hip radiographs with high accuracy, highlighting the future application for population-based opportunistic osteoporosis screening with low cost and high adaptability for a broader population at risk.

Trial registration

TMU-JIRB N201909036.

Development of early complications after treatment of trochanteric fractures with an intramedullary sliding hip screw in a geriatric population

PURPOSE

Although trochanteric fractures (TF) are a frequent event in the geriatric population, studies reporting on complication rates associated with surgical treatment are sparse. Thus, this study investigated the relevance of fracture-, implant-, and surgery-associated complications in TF. Furthermore, the role of possible risk factors for the before mentioned complications was investigated.

METHODS

A consecutive series of patients with TF treated by intramedullary nailing with a sliding screw device was evaluated. Data were sampled retrospectively from the hospital patient information system and anonymized at the source. Demographic data and information regarding fracture pattern, the treatment performed, hospital stay, and evaluation of operative and follow-up radiographs were analyzed. Intraoperative problems (i.e., technical problems with the implant, intraoperative fracture) and postoperative complications were investigated.

RESULTS

Postoperative surgical complications were noted in 11.7%. The most frequent surgical problem was a difficult fracture reduction (13%) and intraoperative fracture dislocation (3.6%). The most frequent postoperative complication was intra-hospital mortality (3.6%), delayed/non-union (2.7%), and a cut-out of the lag screw in the femoral head (2.3%). Implant failure (1,4%) was significantly associated with morbid obesity while cut-out (2,3%) correlated with a higher tip-apex distance (TAD). A complex fracture type and a suboptimal screw position significantly increased the cut-out rate to 5% (p = 0.018).

CONCLUSION

Complications after TF treatment occur frequently. While patient-associated variables such as morbid obesity cannot be influenced by the surgeon, correct fracture reduction and implant positioning remain to be of highest importance.

Enhancement of Hip X-ray with Convolutional Autoencoder for Increasing Prediction Accuracy of Bone Mineral Density

It is very important to keep track of decreases in the bone mineral density (BMD) of elderly people since it can be correlated with the risk of incidence of major osteoporotic fractures leading to fatal injuries. Even though dual-energy X-ray absorptiometry (DXA) is the one of the most precise measuring techniques used to quantify BMD, most patients have restricted access to this machine due to high cost of DXA equipment, which is also rarely distributed to local clinics. Meanwhile, the conventional X-rays, which are commonly used for visualizing conditions and injuries due to their low cost, combine the absorption of both soft and bone tissues, consequently limiting its ability to measure BMD. Therefore, we have proposed a specialized automated smart system to quantitatively predict BMD based on a conventional X-ray image only by reducing the soft tissue effect supported by the implementation of a convolutional autoencoder, which is trained using proposed synthesized data to generate grayscale values of bone tissue alone. From the enhanced image, multiple features are calculated from the hip X-ray to predict the BMD values. The performance of the proposed method has been validated through comparison with the DXA value, which shows high consistency with correlation coefficient of 0.81 and mean absolute error of 0.069 g/cm2.

Evaluation of the Relationship between Osteoporosis Parameters in Plain Hip Radiography and DXA Results in 156 Patients at a Single Center in Turkey

BACKGROUND

The aim of the current study is to determine the relationship between osteoporosis findings in plain X-ray and dual-energy X-ray absorptiometry (DXA) measurement results and to create an alternative diagnostic method for osteoporosis without DXA measurement when necessary.

METHODS

DXA values and hip radiographs of 156 patients were retrospectively analyzed. Singh index (SI), Dorr index (DI), cortical thickness index (CTI), and canal-to-calcar ratio (CCR) measurements from both plain hip radiographs were determined by two observers. The correlation of the DXA parameters (hip total T-score, femoral neck T-score, hip total Z-score, hip total bone mineral density [BMD], and femoral neck BMD) and osteoporosis markers on plain hip radiography (SI, DI, CTI, and CCR) was calculated. In addition, patients were evaluated by dividing them into three groups according to the level of their T-scores (normal, osteopenia, and osteoporosis). In addition, cut-off values were calculated for CTI and CCR.

RESULTS

The mean age was 68.27 ± 8.27 (50-85) years. There was a strong correlation between hip total T-score values and SI, DI, and CTI (r = 0.683, -0.667, and 0.632, respectively), and a moderate correlation (r = -0.495) with CCR. When both hips were compared, there were strong correlations between radiographic parameters (r = 0.942 for SI, 0.858 for DI, 0.957 for CTI, and 0.938 for CCR, all with p < 0.001). When patients divided into three groups according to the T-score level were compared in terms of SI, DI, CTI, and CCR, it was found to be directly related to osteoporosis level (all p < 0.001). In the differentiation of osteopenia and osteoporosis, the cut-off values were 50.4 degrees for CTI and 60.3 degrees for CCR.

CONCLUSION

Good correlations between hip total T-score values and SI, DI, CTI, and CCR (r = 0.683, -0.667, 0.632, and -0.495, respectively) indicate that the presence of osteoporosis can be detected by hip radiography findings without DXA.

Age-Related changes in the morphological features of medial column of the proximal humerus in the Chinese population

Background

Age-related changes in the medial column (MC) of the proximal humerus have a major impact on fracture management; however, the changes in the morphological features remain unclear. This study aimed to investigate the age-related changes in the morphological features of MC and present the morphological grading.

Methods

One hundred computed tomography (CT) images of the proximal humerus of 100 individuals (19-95 years) were retrospectively obtained. The individuals were categorized into five age groups to quantify the differences among different ages; the youngest group (18-44 years) served as the baseline group. Parameters of the morphological features were measured on CT images with multiplanar reconstruction based on an explicit definition of MC, including length, thickness, width, oblique thickness (D_SM), humeral head diameter (D_HM), and ratio (R_SM) of D_SM to D_HM. The morphological grading of MC was presented based on the value of R_SM deviating different standard deviations (SD) from the mean value in the baseline group.

Results

Significant negative correlations were observed between age and the morphological parameters of MC (r ranged from -0.875 to -0.926; all P < 0.05), excluding D_HM (r = 0.081, P = 0.422). Significant differences in the values of morphological feature parameters were detected among the five age groups (all P < 0.001). The highest mean values of morphological feature parameters were observed in the youngest group (18-44 years), which decreased gradually with increasing age until the lowest mean values were observed in the oldest group (≥90 years) (all P < 0.05). The morphological features of MC were categorized into three grades based on the value of R_SM deviating 1.5 SD or 3 SD from the mean value in the baseline group.

Conclusion

Our study shows that the parameter values of morphological features of MC decreased with increasing age. The morphological features of MC could be categorized into three grades. Our findings may provide a more comprehensive insight into age-related changes in the morphological features of MC that facilitate risk stratification and optimize the management of proximal humeral fractures.

Functional Outcome of Hemiarthroplasty of the Hip for Unstable Intertrochanteric Fractures of the Femur in Elderly Patients: A Prospective Study

Introduction It is frequently challenging to treat an unstable intertrochanteric fracture in elderly people by internal fixation because of difficult anatomical reduction, poor bone quality, the need for prolonged bed rest and restricted ambulation. As an alternative to internal fixation, cemented bipolar hemiarthroplasty has been used as a treatment for unstable intertrochanteric fractures to avoid the postoperative immobilization-related complications. The aim of this study was to evaluate the functional and clinical outcomes of primary cemented bipolar hemiarthroplasty for elderly patients with unstable intertrochanteric fractures. Methodology A prospective study was conducted that included 30 patients who were admitted to the apex trauma center at a tertiary care center from January 2019 to August 2020 with unstable intertrochanteric fractures (Association for Osteosynthesis/Orthopaedic Trauma Association, or AO/OTA, types 31-A2.2 and 31-A2.3); patients treated with cemented bipolar hemiarthroplasty, with at least one year of follow-up were included in the study. Basic descriptive statistics were used and the results were presented in frequencies, percentages for categorical variables and means and standard deviations for continuous variables. Results According to the Harris Hip Score, at the end of 12 months, 9 patients (30%) had excellent results, 14 patients (46.67%) had good results, 5 patients (16.67) had fair results, and 2 cases (6.67) had poor results. With cemented hemiarthroplasty, 87.7% of older patients with unstable intertrochanteric fractures were able to walk sooner, and the results were good. Conclusion Hemiarthroplasty of the hip with a cemented bipolar prosthesis appears to be a reliable treatment method for the management of unstable intertrochanteric fractures in elderly patients with osteoporosis; it allows for early ambulation and leads to a favorable functional outcome in most patients following surgery.

Survival and reproduction in Arctic caribou are associated with summer forage and insect harassment

Investigators have speculated that the climate-driven “greening of the Arctic” may benefit barren-ground caribou populations, but paradoxically many populations have declined in recent years. This pattern has raised concerns about the influence of summer habitat conditions on caribou demographic rates, and how populations may be impacted in the future. The short Arctic summer provides caribou with important forage resources but is also the time they are exposed to intense harassment by insects, factors which are both being altered by longer, warmer growing seasons. To better understand the effects of summer forage and insect activity on Arctic caribou demographic rates, we investigated the influence of estimated forage biomass, digestible energy (DE), digestible nitrogen (DN), and mosquito activity on the reproductive success and survival of adult females in the Central Arctic Herd on the North Slope of Alaska. We tested the hypotheses that greater early summer DN would increase subsequent reproduction (parturition and late June calving success) while greater biomass and DE would increase adult survival (September–May), and that elevated mosquito activity would reduce both demographic rates. Because the period when abundant forage DN is limited and overlaps with the period of mosquito harassment, we also expected years with low DN and high harassment to synergistically reduce caribou reproductive success. Examining these relationships at the individual-level, using GPS-collared females, and at the population-level, using long-term monitoring data, we generally found support for our expectations. Greater early summer DN was associated with increased subsequent calving success, while greater summer biomass was associated with increased adult survival. Mosquito activity was associated with reductions in adult female parturition, late June calving success, and survival, and in years with low DN, had compounding effects on subsequent late June calving success. Our findings indicate that summer nutrition and mosquito activity collectively influence the demographic rates of Arctic caribou, and may impact the dynamics of populations in the future under changing environmental conditions.

The predictive value of the Singh index for the risk of InterTAN intramedullary fixation failure in elderly patients with intertrochanteric fractures

Background

To investigate the predictive value of the Singh index for the risk of InterTAN intramedullary fixation failure in elderly patients with intertrochanteric fracture to guide clinical treatment.

Methods

A total of 360 patients were divided into the Singh (I ~ II) (n = 120), Singh (III ~ IV) (n = 120) and Singh (V ~ VI) (n = 120) groups. Visual analog scale (VAS) and Harris scores were recorded at 1, 6, 12, 18 and 24 months after the operation. The correlation between the Singh index and the T-score of the total hip and femoral neck was analyzed. Logistic regression was used to analyze the relationship between the Singh index and internal fixation failure; the types of internal fixation failure were also analyzed.

Results

The Harris scores of the Singh (I ~ II) group were lower than those of the Singh (III ~ IV) and Singh (V ~ VI) groups 12, 18 and 24 months after surgery (P < 0.05). The Singh index was significantly correlated with the T-score of the total hip and femoral neck (P = 0.00, r = 0.89; P = 0.00, r = 0.83). The Singh (I ~ II) group had the lowest internal fixation survival rate within 24 months (P = 0.01). The Singh index was an independent predictor of internal fixation failure (P < 0.05). Lag screw cutting-out was the main type of internal fixation failure in the three groups (P = 0.00).

Conclusion

The Singh index is significantly correlated with the bone mineral density of the femoral neck and total hip. The Singh (I ~ II) group had lower Harris scores and a lower internal fixation survival rate than the other two groups. The Singh index is an independent predictor of internal fixation failure, especially lag screw cutting-out, after InterTAN fixation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05741-8.

Deep Radiomics-based Approach to the Diagnosis of Osteoporosis Using Hip Radiographs

PURPOSE

To develop and validate deep radiomics models for the diagnosis of osteoporosis using hip radiographs.

MATERIALS AND METHODS

A deep radiomics model was developed using 4924 hip radiographs from 4308 patients (3632 women; mean age, 62 years ± 13 [SD]) obtained between September 2009 and April 2020. Ten deep features, 16 texture features, and three clinical features were used to train the model. T score measured with dual-energy x-ray absorptiometry was used as a reference standard for osteoporosis. Seven deep radiomics models that combined different types of features were developed: clinical (model C); texture (model T); deep (model D); texture and clinical (model TC); deep and clinical (model DC); deep and texture (model DT); and deep, texture, and clinical features (model DTC). A total of 444 hip radiographs obtained between January 2019 and April 2020 from another institution were used for the external test. Six radiologists performed an observer performance test. The area under the receiver operating characteristic curve (AUC) was used to evaluate diagnostic performance.

RESULTS

For the external test set, model D (AUC, 0.92; 95% CI: 0.89, 0.95) demonstrated higher diagnostic performance than model T (AUC, 0.77; 95% CI: 0.70, 0.83; adjusted P < .001). Model DC (AUC, 0.95; 95% CI: 0.92, 0.97; adjusted P = .03) and model DTC (AUC, 0.95; 95% CI: 0.92, 0.97; adjusted P = .048) showed improved diagnostic performance compared with model D. When observer performance without and with the assistance of the model DTC prediction was compared, performance improved from a mean AUC of 0.77 to 0.87 (P = .002).

CONCLUSION

Deep radiomics models using hip radiographs could be used to diagnose osteoporosis with high performance.Keywords: Skeletal-Appendicular, Hip, Absorptiometry/Bone Densitometry© RSNA, 2022.

Capture Order Across Social Bathyergids Indicates Similarities in Division of Labour and Spatial Organisation

The social mole-rats of the family Bathyergidae show elaborate social organisation that may include division of labour between breeders and non-breeders as well as across non-breeders within their groups. However, comparative behavioural data across the taxa are rare and contrasts and similarities between species are poorly understood. Field studies of social bathyergids usually involve capturing all group members until the entire group is captured. Because each animal is only captured once and traps are typically placed in close proximity to active foraging areas, the order in which animals are captured provides an indication of the foraging activity of different individuals and of the spatial organisation of the group within the burrow system. Here, we compare the association of capture order with breeding status, sex, and body mass in four species and subspecies of social bathyergids, which vary in group size and represent all three social genera within the family Bathyergidae. We show that in naked and Damaraland mole-rats (Heterocephalus glaber and Fukomys damarensis), male and female breeders are captured later than non-breeders, whereas in two different subspecies of the genus Cryptomys only female breeders are captured later than non-breeders. The effect sizes vary largely and are 10 times larger in naked mole-rats as compared to Fukomys and 3–4 times larger than in Cryptomys. Among non-breeders, sex effects are notably absent in all species and body mass predicted capture order in both naked and Damaraland mole-rats. In naked mole-rats, larger non-breeders were captured earlier than smaller ones, whereas in Damaraland mole-rats intermediate-sized non-breeders were captured first. Our data suggest that there are similarities in behavioural structure and spatial organisation across all social bathyergid species, though the most pronounced differences within groups are found in naked mole-rats.

Is Radiographic Osteoporotic Hip Morphology A Predictor For High Mortality Following Intertrochanteric Femur Fractures?: Osteoporotic Hip Morphology & Mortality

INTRODUCTION

Factors related to mortality after intertrochanteric femur fractures (ITFF) have been investigated intensively in the literature except for radiographic osteoporotic hip morphology. The aim of this study is to investigate the relationship between mortality and radiographic osteoporotic hip morphology of patients with ITFF.

PATIENTS AND METHODS

Patients who underwent surgery between the dates of January 2012 and June 2018 due to ITFF were retrospectively reviewed. Osteoporotic status of the proximal femur was determined based on Singh Index grading and Dorr classification systems on preoperative anteroposterior pelvis radiographs of contralateral hips. The mortality rates of the patients were measured at 1st, 3rd, 6th, and 12th months. For controlling the confounders, multiple regression analysis was performed.

RESULTS

A total of 321 consecutive ITFFs were included in the study. The mean age of the patients was 81.5 ± 6.6 years. All patients were treated with osteosynthesis utilizing a cephalomedullary nail. The overall mortality rates at 1st, 3rd, 6th, and 12th months were 7.2%, 13.4%, 16.2%, 22.7%, respectively. There was 2.196 (1.140 - 4.229) folds increase in the mortality rate of patients with the Dorr type C femurs at 6th month (p=0.019). However, Singh index grade was not significantly associated with mortality.

CONCLUSION

Patients with Dorr type C femur seem to have 2.1 times increased mortality at 6th months following ITFFs. A simple anteroposterior pelvis radiograph obtained during the initial evaluation of the patients may be used to estimate the mortality rate after ITFF.

Childhood Emotional Maltreatment and Romantic Relationships: The Role of Compassionate Goals

Past research indicates that childhood emotional maltreatment (CEM) undermines the quality of adult romantic relationships by fostering negative characteristics in survivors. Two longitudinal studies investigated the hypothesis that decreased compassionate goals toward partners over time explain the association between CEM and declining relationship quality. In Study 1, CEM predicted decreased compassionate goals over time, which in turn predicted decreased relationship quality in individuals in romantic relationships. Study 2 replicated this effect in romantically involved couples and showed that partners' high compassionate goals attenuated the decline in compassionate goals associated with reported CEM. These results point to the importance of examining how CEM may affect positive relationship processes and the protective roles of partners' compassionate goals.

Epidemiological investigation of hospitalized patients with traumatic fractures: a cross-sectional study

OBJECTIVE

This study was performed to explore major risk factors for traumatic fracture by comparing related data of hospitalized patients with traumatic fracture and patients with lumbar disc herniation.

METHODS

Patients with traumatic fracture and patients with lumbar disc herniation requiring surgical treatment in the orthopedics department of our hospital from March to May 2018 were divided into a fracture group and a non-fracture group. Clinical data were collected from the two groups by questionnaires. Major risk factors for traumatic fracture were analyzed using multivariate logistic regression.

RESULTS

Univariate analysis showed statistically significant differences in family history of fracture, smoking history, drinking history, sex, sleep duration, chronic disease history, osteoporosis history, age, body mass index, occupation, and education level between the two groups. Multivariate logistic regression analysis showed that patients aged 25 to 44 years were more prone to traumatic fracture than patients aged ≥65 years, male patients were more prone to fracture than female patients, drinking alcohol was a risk factor for traumatic fracture, and sufficient sleep duration (>7 hours/night) was a protective factor for traumatic fracture.

CONCLUSION

Young age, male sex, and drinking are risk factors for traumatic fracture, whereas sufficient sleep duration is a protective factor.

Evaluation of Singh Index and Osteoporosis Self-Assessment Tool for Asians as risk assessment tools of hip fracture in patients with type 2 diabetes mellitus

Background

Type 2 diabetes mellitus (T2DM), an epidemic disease around world, has recently been identified as a risk factor for osteoporosis-associated fracture. However, there is no consensus on the best method of assessing fracture risk in patients with T2DM. The aim of this study was to evaluate the usefulness of the Osteoporosis Self-Assessment Tool for Asians (OSTA) and the Singh Index (SI) in hip fracture risk assessment in patients with T2DM.

Methods

We enrolled 261 postmenopausal women with T2DM: 87 had hip fracture resulting from low-energy trauma and 174 age-matched controls had no fracture (two controls per fracture case). Bone mineral density (BMD) was measured with dual-energy X-ray absorptiometry in the lumbar spine and hip region. The SI was obtained from standard antero-posterior radiographs of the pelvis. The OSTA was calculated with a formula based on weight and age. Data were analyzed with descriptive statistics and tests of difference. Receiver operating characteristic analysis was used to determine optimum cutoff values, sensitivity, and specificity of screening methods. Discriminative abilities of different screening tools were compared with the area under the curve (AUC).

Results

There were significant differences in BMD at all sites (lumbar spine, femoral neck, trochanter, and total hip) and in SI between the fracture and non-fracture groups (P < 0.05). There was no significant difference in OSTA between the groups (P > 0.05). The area under the curve was 0.747 (95% CI: 0.680–0.813) for lumbar spine BMD, 0.699 (95% CI: 0.633–0.764) for total hip BMD, 0.659 (95% CI: 0.589–0.729) for femoral neck BMD, 0.631 (95% CI: 0.557–0.704) for trochanter BMD, 0.534 (95% CI: 0.459–0.610) for OSTA, 0.636 (95% CI: 0.564–0.709) for SI, and 0.795 (95% CI: 0.734–0.857) for OSTA plus SI. The AUC for combined OSTA plus SI was significantly superior to other parameters besides BMD of the lumbar spine.

Conclusions

The combination of OSTA plus SI could be a clinical alternative tool for screening of hip fracture risk in large diabetic populations. These tests are inexpensive and simple to perform and could be especially useful in areas where BMD measurement is not accessible.

A Qualitative Examination of the Ward Region of Interest as Imaged on Dual-Energy X-ray Absorptiometry Examinations: The "Wandering Ward Sign"

While analyzing dual-energy X-ray absorptiometry (DXA) examinations, we observed that, on occasion, the Ward region of interest (ROI) was positioned either unexpectedly or differently between successive examinations. When this occurred, it appeared to be either a marker of a compromised examination or of incident disease. This prompted a systematic inquiry. It became apparent that, while in general seeking the region of least areal density, the Ward ROI is positioned differently by the machines available to us from 2 particular manufacturers (General Electric Co. and Hologic Inc.). Three reviews were thus undertaken: (1) a prospective systematic examination of 200 unselected consecutive DXA examinations made with a General Electric Co. machine, 80 having had follow-up examinations and 245 made with a Hologic Inc. device; (2) a prospective systematic examination of 625 consecutive, unselected DXA examinations that were repeat examinations; and (3) a retrospective examination of a file of 86 cases collected for pedagogical purposes, predominantly made with a Hologic Inc. device. The commonest cause of an unusual position of the Ward area was compromised patient positioning or change in body habitus. Changes between examinations were, in addition if less often, apt to reflect physiological change or disease. Unusual positioning or a change in position of the Ward ROI is easily observed. It does not occur frequently, but, when it does, it may be useful in directing attention to either technical factors or incidental diseases. Observation of the position of the Ward ROI may thus be a quality assurance, and occasionally a diagnostic, tool.

The effect of local bone density on mechanical failure after internal fixation of pertrochanteric fractures

INTRODUCTION

The aim of this prospective study was to investigate the effect of local hip bone density on mechanical failure after fixation of pertrochanteric fractures and to establish possible risk factors for the failures.

MATERIALS AND METHODS

A total of 136 consecutive patients presenting a closed unilateral pertrochanteric fracture were enrolled. The patients were treated with a sliding hip screw or an intramedullary nail. Dual energy X-ray absorptiometry measurements for bone density of the contralateral hip were made within 4 weeks postoperatively. Follow-up evaluations on the standard radiographs were documented for any mechanical failure including loss of reduction, screw or blade cut-out, lateral migration of the screw or blade, and implant breakage. Secondary outcomes were also recorded including patient characteristics and fixation construct variables as possible predictors for mechanical failure.

RESULTS

At a minimum of 2 years of follow-up, 38 patients were reported with mechanical failure at an estimated risk of 27.9 %. The local bone density measurements for the study population showed no difference between patients with (0.710 g/cm(2)) and without (0.726 g/cm(2)) mechanical failure (P = 0.180). We also observed no significant correlation between local bone density and failure in patients with good fracture reduction (P = 0.862). The multivariate regression analysis identified fracture type (P < 0.001) and quality of fracture reduction (P < 0.001) as being independent predictors for mechanical failure, whereas local bone density was not (P = 0.658).

CONCLUSIONS

Local hip bone density does not appear to have a significant influence on mechanical failure after internal fixation of pertrochanteric fractures. Stable fractures and fractures with good reduction are expected to obtain satisfactory outcomes.

Fast and easy preoperative estimation of cancellous bone mineral density in patients with proximal femur fractures

INTRODUCTION

Postoperative complications after hip fractures in osteoporotic bone such as implant cutout can be reduced by the use of specially designed implants or additional cement augmentation. It is not yet clear at which degree of osteoporosis, patients will profit from implant augmentation or specially designed implants for geriatric patients. As the surgeon ideally should obtain information on local bone quality at the site of implant anchorage already preoperatively, the aim of the study was to develop an easily applicable radiographic method to estimate bone quality in those patients.

MATERIALS AND METHODS

75 patients with unilateral hip fracture were included. Preoperatively, a CT scan with a calibration device was conducted. Postoperatively, DXA scans were performed. The proposed method measures local cancellous bone mineral density in the contralateral and uninjured femoral head. As a control, 15 young and healthy non-osteoporotic subjects were included. Inter- and intraobserver reliability was investigated for a subgroup of 20 patients.

RESULTS

Study group patients had a mean BMD measured by CT scans of 194.2 mg/cm(3) (SD 40.4). There was a statistically significant correlation with data from DXA scans (r = 0.706, p < 0.001). The control group was significantly younger and showed a significantly higher BMD when compared to the study group (p < 0.001). Reliability evaluation showed no statistically significant difference in inter- and intraobserver measurements. Interclass correlation proved to be very high.

CONCLUSION

The proposed method is an easily applicable, reliable and useful tool to estimate bone quality preoperatively using the contralateral hip as a reference. Obtained data may facilitate the decision-making towards the use of further therapeutic measures to improve implant anchorage in osteoporotic bone such as bone cement augmentation. Thus, our method allows for a more individualized surgical treatment of hip fracture patients adapted to the estimated cancellous bone quality of the patient.

The Singh Index does not correlate with bone mineral density (BMD) measured with dual energy X-ray absorptiometry (DXA) or peripheral quantitative computed tomography (pQCT)

The Singh Index (SI), a classification system by which the severity of osteoporosis is assessed based on plain radiographs, is a renowned, simple and inexpensive form of evaluating osteoporosis. The aim of this study was to evaluate the correlation between the SI and bone mineral density (BMD) as measured by dual energy X-ray absorptiometry (DXA) and peripheral quantitative computed tomography (pQCT). The SI was evaluated in 128 cadaveric femora (64 patients, mean age 66.7 years, range 24-89 years) by three independent observers, all blinded to plain radiographs. BMD was also analysed by means of DXA and pQCT in the cadaveric femora. The mean interrater correlation was found to be 0.629. The correlation of the mean BMD measured by DXA (DXA-BMD) and SI was found to be poor, with r = 0.49. The corresponding sensitivity of 45.2 % and specificity of 92.3 % were even poor. The BMD measured by pQCT (pQCT-BMD) also revealed a poor correlation with SI, such that r = 0.337 and r = 0.428 for the trochanteric and neck regions, respectively. Due to the poor correlation of the SI with BMD and the poorer interrater correlation, the SI should be rejected as a tool for evaluating osteoporosis. The SI was found to be too imprecise and is therefore unsuitable for diagnosing osteoporosis and osteopenia.

Functional outcomes after total hip arthroplasty for the acute management of acetabular fractures: 1- to 14-year follow-up

OBJECTIVE

This study reports the complications and functional outcomes in patients treated acutely with combined open reduction internal fixation (ORIF) and immediate total hip arthroplasty (THA) for displaced comminuted acetabular fractures.

DESIGN

Single surgeon retrospective case series.

SETTING

Level 1 trauma center.

PATIENTS

Thirty-three consecutive patients (18 women; mean age, 66 years) from 1996 to 2011 with an average follow-up of 5.6 years (range, 1-14.3 years) were included in this study.

INTERVENTION

ORIF and immediate THA.

MAIN OUTCOME MEASUREMENTS

Oxford Hip Score and reoperation.

METHODS

All patients had at least 1 year of telephone or clinical follow-up. Postoperative complications, reoperations, and available radiographs were reviewed.

RESULTS

Six patients died of causes unrelated to their injuries or surgery; before death, these patients had well-functioning hips. There was a 15% complication rate. At last follow-up, 94% of hips remained in situ and were functioning well. The average Oxford Hip Score at final follow-up was 17 (range, 12-32), with 93% of patients reporting good to excellent function. There was no statistical association between fracture type, age, or fixation type and outcome.

CONCLUSIONS

Acute ORIF and immediate THA for selected acetabular fractures is a safe viable treatment option with good to excellent functional outcomes and may reduce the need for 2 separate operations in many patients. Functional outcomes are equivalent to those after primary THA for osteoarthritis. This study does not address at which age acute THA is a cost-effective treatment option.

LEVEL OF EVIDENCE

Therapeutic level IV. See Instructions for authors for a complete description of levels of evidence.

Failure after osteosynthesis of trochanteric fractures. Where is the limit of osteoporosis?

SUMMARY

The aim of this study is to identify osteoporosis values, beyond which there is a high risk of osteosynthesis failure. Bone mineral density (BMD) of 30 cadaveric femora with a pertrochanteric fracture osteotomy was correlated to the risk of cut out after osteosynthesis on a biomechanical testing approach. For a BMD less than 250 mg/cm(3), there is a high risk of fixation failure after surgical treatment of pertrochanteric fractures. This value can be regarded as a reference value for future experimental and clinical studies.

INTRODUCTION

Despite continuous modification of intramedullary load carriers for the surgical stabilization of trochanteric fractures, cut out remains the most frequent complication. The aim of this experimental study was to identify threshold osteoporosis values, beyond which there is a high risk of osteosynthesis failure.

METHODS

Bone mineral density (BMD) of 30 cadaveric femora was recorded for the femoral head by QCT measurement. Subsequently, a standardized osteotomy mimicking an unstable trochanteric type fracture was stabilized by intramedullary nailing. The constructs were loaded axially at a force of 2,100 N up to 20,000 cycles. Cut out at the femoral head was documented by radiograph. Statistical evaluation of the cohort group was performed by calculation of relative risk in relation to the BMD values.

RESULTS

In total, there were six cases of cut out after 10,000 cycles. The incidence of cut out for BMD less than 250 mg/cm(3) was 0.55 (5 of 9) and for BMD greater than 250 mg/cm(3), it was 0.05 (1 of 21). Therefore, the relative risk of cut out for BMD <250 mg/cm(3) is 11× greater than for a BMD >250 mg/cm(3). After 20,000 cycles, an additional test caused one cut out (relative risk of cut out for a BMD <250 mg/cm(3) 5.8).

CONCLUSIONS

For a BMD less than 250 mg/cm(3), there is a high risk of fixation failure after surgical treatment of pertrochanteric fractures. Although this value is based on an experimental in vitro study design with all its associated limitations, it can be regarded as a reference value for future experimental and clinical studies.

Quantitative score system for the surgical decision on adult femoral neck fractures

Surgical decision making for femoral neck fractures is currently based on factors such as patient age, fracture type, and medical condition, lacking a quantitative standard. The treatment protocol based on such qualitative assessment has poor operability, greatly affected by the surgeon's subjective factors. As a result, a quantitative score system (QSS) focusing on 5 factors--age, fracture type, bone mineral density, activities of daily living, and medical comorbidities--with a total score of 25 is designed to deal with adult femoral neck fractures. The higher the score, the worse the patient's physiological condition. According to our clinical experience, patients with 1 to 11 points should be treated with internal fixation; patients with 12 to 17 points with total hip arthroplasty (THA), and patients with 18 to 22 points with hemiarthroplasty. Patients with 22 to 25 points should be treated with internal fixation due to the high surgical risk of arthroplasty caused by poor physiological condition. Three hundred seventy-five adult femoral neck fractures were treated on the basis of QSS for this 2-year prospective study. Of these, 242 were treated with low-score internal fixation, 60 with THA, 55 with hemiarthroplasty, and 18 with high-score internal fixation. The revision rates 2 years postoperatively in the low-score internal fixation, THA, and hemiarthroplasty groups were 15.3%, 5.0%, and 5.5%, respectively, which were lower than those from a meta-analysis (internal fixation, 35%; THA, 16%). This QSS helps surgical decision making regarding the treatment choice for adult patients with femoral neck fractures, and good results in preliminary clinical practice have been achieved.

Can bone quality be predicted accurately by Singh index in patients with rheumatoid arthritis?

The aim of this study was to evaluate Singh index as a simple and inexpensive means of estimation of bone quality in patients with rheumatoid arthritis. Singh index evaluation was made on digital pelvis radiographs in 50 consecutive patients by three observers. Bone mineral density T scores of the spine and left proximal femur were assessed using dual energy X-ray absorptiometry. Singh index was correlated with densitometry measurements after grouping the patients as normal, osteopenia and osteoporosis. Intra- and interobserver agreements were evaluated by kappa correlations. Sensitivity, specificity, positive and negative predictive values and likelihood ratio's of Singh index were calculated. Both intra- and interobserver agreements were 0.71 (range, 0.69 to 0.72) on average. Singh index proved highly sensitive for the diagnosis of osteopenia at the proximal femur (91%) and spine (90%), whereas the specificity of Singh index for identifying of osteoporosis at the femoral neck (93%) and spine (91%) was higher than sensitivity. Predictive values for osteoporosis at the proximal femur and spine were acceptable and positive likelihood ratios of Singh index for osteopenia and osteoporosis at the proximal femur were 2.4 and 10.1, respectively. Singh index can identify osteoporosis with a high specificity in patients with rheumatoid arthritis. However, the patients who are graded as osteopenia by the Singh index should undergo further evaluation with dual energy X-ray absorptiometry.

Evaluation of the Singh index and femur geometry in osteoporotic women

We aimed to compare the Singh index with bone mineral density (BMD) by dual-energy X-ray absorptiometry (DXA), body mass index (BMI) and femur geometry in the right proximal femur of osteoporotic women, using different statistical tests. Radiographs of each patient were assessed to determine the Singh index by five observers. The observers consisted of a consultant radiologist, physical therapist and anatomists who studied the series of radiographs. They were asked to apply the Singh index by comparing the trabecular bone pattern in the proximal right femur with the reference scale published by Singh et al. [1]. This has a six point scale from grade VI to grade I. We evaluated 47 osteoporotic women in this study. The subjects’ mean age, weigth, and height were 63,21 ± 10,106, 66,72 ± 12.523, 154,94 ± 7,026 respectively. We found a significant relationship between the Singh index and BMD. The Singh index correlated significantly with hip axis length, femoral neck diamater and trochanteric width. And, BMD correlated significantly with femoral head and neck diameter, femoral neck cortex width, medial calcar femoral cortex width and femoral shaft cortex width. The evaluation of the Singh index grades in its self, there was a significant relation among them.

Garden I femoral neck fractures in patients 65 years old and older: is conservative functional treatment a viable option?

INTRODUCTION

Internal fixation is the preferred treatment of Garden I femoral neck fractures in the elderly. High re-operation rates have however been reported, and the results of arthroplasty performed following internal fixation failure are not as good as those of primary arthroplasty. This is why we are advocating functional treatment. Our hypothesis is that this treatment leads to fewer decubitus complications than strict orthopaedic treatment and no more mechanical complications than internal fixation in a selected population sample. Therefore, the objective of our prospective work was: (1) to assess the results of functional treatment of Garden I femoral neck fractures in elderly subjects, and (2) to investigate predictive factors of secondary displacement.

PATIENTS AND METHODS

All patients over age 65 years, admitted for a Garden I femoral neck fracture between January 2006 and May 2008, were included in this prospective study representing 56 cases (57 fractures) with an average age of 82 years. Functional treatment was performed, including early weight-bearing mobilisation, followed by radiographic evaluation at days 2, 7, 21 and 45, then at 3, 6 and 12 months. In the absence of displacement, discharge was planned at day 5 (Non-Displaced [ND] group). Otherwise, arthroplasty was performed (Displaced [D] group). Parker score and Harris Hip Score (HHS) were used for functional evaluation.

RESULTS

The observed displacement rate was 33.3% (19 patients) within an average period of 10 days. In the ND group, one case of osteonecrosis was observed and treated by arthroplasty. The average Parker score was 6.9 and the HHS 82 in the ND group, and 7 and 85, respectively, in the D group. None of the factors studied (age, gender, side, fracture type, inclination angle, degree of outward displacement, sagittal displacement, general status) was statistically predictive of final displacement.

DISCUSSION

The medical complication rate was only 7% in our series, which seems to be lower than that resulting from orthopaedic treatment. The observed secondary displacement rate seemed to be higher than the rate found in the literature on surgical treatment (5.4 to 20%), but the osteonecrosis rate appeared to be lower (11 to 25%). In addition, surgical treatment was the purveyor of specific complications in over 10% of cases.

CONCLUSIONS

The present prospective study with minimum 1-year follow-up shows that functional treatment results in fewer decubitus complications than orthopaedic treatment and a rate of revision surgery comparable to internal fixation since 70% of included patients could have been successfully treated without surgical intervention. However, the investigation of a larger cohort would be necessary to identify predictive factors for the treatment's failure.

LEVEL OF EVIDENCE

Level III prospective non-comparative cohort study.