Study of acetabular erosion and activity level after hemiarthroplasty, in neck of femur fracture patients after a minimum period of 2 years

INTRODUCTION: Neck of femur fractures are one of the devastating injuries of the old age. It is well recognized even from the era of Hippocrates. The exact number of hip fractures worldwide is impossible to determine, but the global incidence in the year 2000 has been estimated at 1.6 million and the projections for the future suggest further increasing numbers. In addition to the suffering of the individual the economic strain on society due to hip fracture is immense. Management of displaced intracapsular hip fracture in elderly remains controversial. Options include hemiarthroplasty or total hip arthroplasty. Total hip arthroplasty has shown better pain relief and clinical outcome, but in the elderly frail population who often suffer from fracture of the neck of the femur, mortality rates are high. Hemiarthroplasty is one of the commonest procedures done for neck of femur fractures. It provides pain relief and early mobilization.The Austin – Moore and Thompson prostheses have been successful implants in treating fracture neck of femur. Disabling pain and acetabular erosions are frequent complications after the use of Moore prosthesis. So in an attempt to retard the acetabular wear, prolong the life of the implant and delay the need for revision surgery the bipolar prosthesis was developed by James E Bateman in Toronto in 1974, which had the advantage of hip motion occuring at 2 interfaces, primarily at the prosthetic interface and secondarily at the metal – cartilage interface, thus minimising the articular wear. This prosthesis was found to be very useful and results were encouraging. However in longterm studies show that the bipolar prosthesis start acting as unipolar prosthesis with time and hence leads to some erosion. However not all patients with acetabular erosions are symptomatic.In our study we have evaluated the acetabular erosion after hemiarthroplasty, in neck of femur fracture patients after a minimum period of 2 years and have tried to correlate it with activity level of the patient. AIM: 1. Early detection of acetabular erosion. 2. To assess the functional outcome after minimum of 2 years after hemiarthroplasty by modified UCLA score. 3. To correlate the functional activity level and radiological acetabular erosion. MATERIALS AND METHODS: Source of data: This is a retrospective radiological and clinical study. The post hemiarthroplasty plain radiographs, showing AP view of hip joint taken in the Department of Radiodiagnosis, PSGIMS&R will be studied along with activity level assessment. Mode of data collection: By Convenient sampling method, all the patients undergone hemiarthroplasty, for fracture neck of femur after minimum of 2 years were assessed both radiologically and clinically. Inclusion criteria: All patients operated for neck of femur fracture with hemiarthroplasty after a minimum period of 2 years. Exclusion criteria: 1.) Surgical site hip Infection. 2.) Any pre existing pathologies around the hip. 3) Previous hip surgeries. 4.) Post-operative periprosthetic fractures. 5). Neurological conditions like CVA, Parkinsonism. X-ray technique: A plain anteroposterior view of the operated hip joint is taken and assessed for acetabular erosion grading. Patient positioned in supine, using digital X-RAY, casette tube distance is set to 100cms and the beam is centered directly over the hip. Radiological assessment Activity level assessment: LITERATURE REVIEW: Thompson Hemiarthroplasty and Acetabular erosion: T.W. Philips, London, Ontario, Canada, from the Orthopaedic research laboratory, St.Joseph health centre and division of Orthopaedic surgery, University of Western Ontario, London The prevalence, severity and clinical importance of acetabular erosion secondary to hemiarthroplasty of the hip are largely unknown. The factor that had the highest correlation with severity of the erosion were the level of physical activity and the duration of follow-up. Author`s analysis shows that the erosion progressed at an average of 3% per year in active patients. Post operative level of activity is determined by patient`s age and type of residence at the time of fracture. Clinical relevance of acetabular erosion in young patients with a bipolar hip prosthesis: G. Kiekens, J. Somville, A. Taminiau- University Hospital Antwerp, UZA, Belgium, Department of Orthopaedics and Trauma, University Hospital Leiden, LUMC, The Netherlands, Department of Orthopaedics. Young patients who had undergone bipolar hemiarthroplasty for proximal femur malignant tumor resection were followed up for a mean time of 81.8 months. The erosion and activity were assessed by x-rays and clinical examination. They did not report pain and had a good quality of life. The risk of late acetabular erosions were predicted by anticipated longevity of the patient and the level of activity. Degeneration of acetabular articular cartilage to bipolar hemiarthroplasty: Kyoung Ho Moon, Jun soon kang, Tong joo lee, Sang hyeop lee, Sung wook choi and Man hee won- Department of Orthopaedics, Inha university Hospital, Incheon, Korea. Considering the life expectancy and activity of patients who require hip arthroplasty, it could be predicted by radiologically measuring the degeneration rate of the acetabular articular cartilage. Measurement of acetabular erosion: The effect of pelvic rotation on common landmarks. R.G. Wetherel, A.A. Amis, F.W. Heatley from St. Thomas` hospital and imperial college, London. The line drawn between acetabular margins are significantly more accurate for proximal migration, than teardrop, sacroiliac or sacroiliac-symphysis line. Line drawn tangential to the brim and through the horizontal mid-point of the obturator foramen is more accurate than Kholer`s line, ilio-ischial or iliopubic line. In combination the two lines can give more accurate assessment and they are less affected by the difference in rotation commonly found in plain radiographs. Retrospective evaluation of bipolar hemiarthroplasty in fracture of the proximal femur North American Journal of Medical Sciences 2010 September, Vol 2. No.9 The aim of the study is to find out which treatment option can lead to a best clinical and functional outcome. It is concluded as 2 years result of bipolar hemiarthroplasty is good but THR- total hip replacement was found to be better. CONCLUSION: As the duration after surgery and activity level increases, the acetabular erosion rate increase. Long term study is needed to assess the erosion level which will give an insight into the factors influencing erosion and it can be prevented

Uncomplicated Traumatic Injury of Pelvic Bone

В учебном пособие дана классификация повреждений таза, описаны методы лечения перелом костей таза, клиника, диагностика и принципы лечения переломов костей таза. Описан физиотерапевтический курс восстановительного лечения больных с повреждениями таза. Учебно-методическое пособие рассчитано на студентов медицинских институтов, врачей-травматологов, врачей-хирургов, врачей-интернов, врачей-анестезиологов.In the tutorial the classification of pelvic injuries, the methods of treating pelvic fractures, clinical manifestations, diagnosis and principles of treatment of fractures of the pelvis. Physiotherapy course described reductive treatment of patients with pelvic injuries. Teaching manual is designed for medical students, doctors and traumatologists, surgeons, medical interns, anesthesiologists

A Prospective study of Effectiveness of Various Methods of Fixation of Neck of Femur Fracture in Adults

16 adults with neck of femur fracture, treated either with Titanium cancellous screw fixation or Titanium sliding hip screw were followed up for 2 year with clinical scoring and MRI. 93% fractures united. Their Harris Hip score were near normal in 66% cases. According to Steinberg classification, MRI of five patients had avascular necrosis (AVN) (Stage II =3, stage I = 2) 4 of these had high velocity injury. Three patients with AVN had poor results while two (stage 1) had fair results. Functional recovery and patient’s ability to do their daily activities did not correlate with post-operative MRI findings of AVN

Computer-aided diagnosis of complications of total hip replacement X-ray images

Hip replacement surgery has experienced a dramatic evolution in recent years supported by the latest developments in many areas of technology and surgical procedures. Unfortunately complications that follow hip replacement surgery remains the most challenging dilemma faced both by the patients and medical experts. The thesis presents a novel approach to segment the prosthesis of a THR surgical process by using an Active Contour Model (ACM) that is initiated via an automatically detected seed point within the enarthrosis region of the prosthesis. The circular area is detected via the use of a Fast, Randomized Circle Detection Algorithm. Experimental results are provided to compare the performance of the proposed ACM based approach to popular thresholding based approaches. Further an approach to automatically detect the Obturator Foramen using an ACM approach is also presented. Based on analysis of how medical experts carry out the detection of loosening and subsidence of a prosthesis and the presence of infections around the prosthesis area, this thesis presents novel computational analysis concepts to identify the key feature points of the prosthesis that are required to detect all of the above three types of complications. Initially key points along the prosthesis boundary are determined by measuring the curvature on the surface of the prosthesis. By traversing the edge pixels, starting from one end of the boundary of a detected prosthesis, the curvature values are determined and effectively used to determine key points of the prosthesis surface and their relative positioning. After the key-points are detected, pixel value gradients across the boundary of the prosthesis are determined along the boundary of the prosthesis to determine the presence of subsidence, loosening and infections. Experimental results and analysis are presented to show that the presence of subsidence is determined by the identification of dark pixels around the convex bend closest to the stem area of the prosthesis and away from it. The presence of loosening is determined by the additional presence of dark regions just outside the two straight line edges of the stem area of the prosthesis. The presence of infections is represented by the determination of dark areas around the tip of the stem of the prosthesis. All three complications are thus determined by a single process where the detailed analysis defer. The experimental results presented show the effectiveness of all proposed approaches which are also compared and validated against the ground truth recorded manually with expert user input

Treatment of the late complications of hip and femur fractures

Orthopedic surgeons deal with deformities, diseases of bones and joints, and injuries to the musculoskeletal system. Orthopedic injuries are injuries to the skeletal system which consists of bones, joints and supporting structures like muscles, cartilage, ligaments and tendons. The term "orthopedic injury" includes fractures (broken bones), dislocated joints (dislocation) and torn or ruptured tendons, muscles or ligaments. The term "fracture" is defined as the disruption in the integrity of a bone often called a break or crack. This may involve injury to the bone marrow, periosteum, and adjacent soft tissues

Treatment of the late complications of hip and femur fractures

Orthopedic surgeons deal with deformities, diseases of bones and joints, and injuries to the musculoskeletal system. Orthopedic injuries are injuries to the skeletal system which consists of bones, joints and supporting structures like muscles, cartilage, ligaments and tendons. The term "orthopedic injury" includes fractures (broken bones), dislocated joints (dislocation) and torn or ruptured tendons, muscles or ligaments. The term "fracture" is defined as the disruption in the integrity of a bone often called a break or crack. This may involve injury to the bone marrow, periosteum, and adjacent soft tissues

Treatment of the late complications of hip and femur fractures

Orthopedic surgeons deal with deformities, diseases of bones and joints, and injuries to the musculoskeletal system. Orthopedic injuries are injuries to the skeletal system which consists of bones, joints and supporting structures like muscles, cartilage, ligaments and tendons. The term "orthopedic injury" includes fractures (broken bones), dislocated joints (dislocation) and torn or ruptured tendons, muscles or ligaments. The term "fracture" is defined as the disruption in the integrity of a bone often called a break or crack. This may involve injury to the bone marrow, periosteum, and adjacent soft tissues

Segmentation and Fracture Detection in X-ray images for Traumatic Pelvic Injury

Due to the risk of complications such as hemorrhage, severe pelvic trauma is associated with a high mortality rate. Prompt medical treatment is therefore vital. However, the complexity of the injuries can make successful diagnosis and treatment challenging. By generating predictions and recommendations based on patient data, computer-aided decision support systems have the potential to assist physicians in improving outcomes. However, no current system considers features automatically extracted from medical images. This dissertation describes a system to extract diagnostic features from pelvic X-ray images that can be used as input to the prediction process; specifically, the presence of fracture and quantitative measures of displacement. Feature extraction requires prior identification of separate structures of interest within the pelvis. The proposed system therefore incorporates a hierarchical segmentation algorithm which is able to automatically extract multiple structures in a single pass, using a combination of anatomical knowledge and computational techniques such as directed Hough Transform. This algorithm also applies a novel Spline/ASM segmentation method which combines cubic spline interpolation with a deformable model approach which maintains curved contours and provides local control over segmentation. In order for the proposed system to be used as a component in a computerized decision support system, segmentation is designed to be entirely automatic. Furthermore, Spline/ASM is suitable for many other segmentation applications where the objects of interest show curved contours. After successful segmentation, fracture detection is performed on the pelvic ring and pubis structures, using an algorithm based on wavelet transform, anatomical information and boundary tracing. A method is also developed to calculate quantitative measures of symphysis pubis displacement that may indicate pelvic instability and prove useful in identifying fracture patterns. Finally, X-ray features are combined with patient demographics and physiological scores for generation of predictive rules for injury severity, with promising current results. This indicates the potential diagnostic value of the extracted features, and in turn the usefulness of the proposed radiograph analysis component in a larger decision support system

Management of pelvic ring injuries

Jan Lindahl: MANAGEMENT OF PELVIC RING INJURIES Unstable pelvic ring injuries are relatively rare injuries, but they constitute a major cause of death and disability in high-energy polytrauma patients Massive hemorrhage is the leading cause of potentially preventable death following a blunt pelvic trauma. The overall aim of surgical treatment for unstable pelvic ring injuries is to restore the pelvic anatomy and perform neural decompression, thus allowing normal function with a low rate of complications. This doctoral thesis was initiated to investigate the outcomes of acute and definitive management strategies for unstable pelvic ring injuries. The first study investigated the radiological and functional results of treating type B and C pelvic injuries with an anterior external fixation frame. The second study focused on identifying factors for early predictions of mortality-related outcome and prognosis in patients with pelvic fracture-related arterial bleeding that were treated with transcatheter angiographic embolization (TAE). The third study investigated the outcomes of type C pelvic fractures treated with standardized reduction and internal fixation methods. The fourth study evaluated outcomes and identified prognostic factors for operatively-treated, H-shaped sacral fractures with spinopelvic dissociation. Study I showed that an anterior external fixator failed to achieve and properly maintain reduction in 75% of type B open book injuries and in nearly all (95%) type C pelvic ring injuries. Therefore, an external frame is not a suitable method of treatment for the most unstable pelvic ring injuries as a definitive treatment. The current clinical applications of anterior pelvic external fixators comprise the resuscitation phase, initial fracture stabilization phase, and sometimes, in complex injuries (type C), the definitive phase for fixation of the anterior part of the pelvic ring, in conjunction with posterior internal fixation. Study II of pelvic fracture related arterial bleedings showed that the worst prognosis was related to exsanguinating bleeding from the main trunk of the internal or external iliac artery (large pelvic arteries) or from multiple branches of the internal or external iliac vasculature (high vessel size score). Definitive control of arterial bleeding was achieved with TAE in all patients. In massive hemorrhage with several bleeding arteries uni- or bilaterally, it is reasonable to use non-selective embolization by promptly occluding the main trunk of the internal iliac artery, either uni- or bilaterally. Study III of operatively treated type C pelvic fractures revealed that, internal fixation of injuries in the posterior and anterior pelvic ring provided excellent or good radiological results in 90% of cases. Additionally, because a reduction with displacement less than or equal to 5 mm was more often associated with a good functional outcome, that should be the goal of operative management. However, the prognosis is also often dependent on associated injuries, particularly a permanent lumbosacral plexus injury. The results favoured internal fixation of all the injured elements of the pelvis for improved stability and a more accurate anatomical result in the entire pelvic ring. The H-shaped sacral fracture with spinopelvic dissociation is a rare injury pattern. Study IV revealed that lumbopelvic fixation was a reliable treatment method. The study also showed that neurological recovery and clinical outcome were associated with the degree of initial translational displacement of the transverse sacral fracture component. Permanent neurological deficits were more frequent and the clinical outcome was worst in completely displaced transverse sacral fractures. An accurate operative reduction of all sacral fracture components was associated with better neurological recovery and clinical outcome. We conclude, that with appropriate treatment of unstable pelvic ring injuries, and associated injuries in other organs, it is possible to achieve better survival rates and functional results, and to reduce long-term disability.Jan Lindahl: LANTIORENKAAN MURTUMIEN HOITO (MANAGEMENT OF PELVIC RING INJURIES) Lantiorenkaan murtumat ovat suhteellisen harvinaisia vammoja käsittäen 1% kaikista sairaalahoitoa vaativista murtumista Suomessa. Epätukevat lantiorenkaan murtumat syntyvät yleensä suuren vammaenergian seurauksena ja niihin liittyy usein muiden kehonosien vammoja. Massiivinen verenvuoto on merkittävin ja usein estettävissä oleva kuolinsyy tylpällä vammamekanismilla syntyneissä lantiorenkaan vammoissa. Mikäli akuuttivaiheen hoito ei ole tehokasta, massiivinen verenvuoto johtaa sydämen ja verenkierron pettämiseen ja potilaan kuolemaan. Tämän väitöskirjatutkimuksen tarkoituksena oli selvittää: 1) ulkoisen tukilaitteen soveltuvuus B- ja C-tyypin lantiorenkaan murtumien lopulliseksi hoitomuodoksi, 2) hengenvaarallisten, runsaasti vuotavien lantionmurtumien alkuvaiheen vuodon tukkimista embolisaation (TAE) avulla ja samalla kartoittaa riskitekijöitä, jotka ennustavat huonoa lopputulosta ja potilaan kuolemaa vaikeimmin vammautuneiden lantionmurtumapotilaiden kohdalla, 3) C-tyypin murtumien kohdalla standardoidun leikkaushoidon ja sisäisen kiinnitysmenetelmän luotettavuutta ja hoidon pitkäaikaistulokset ja 4) ristiluun vaikeimpien ns. H-tyypin murtumien leikkaushoidon luotettavuutta sekä saavutetun asennonkorjauksen, murtumakiinnityksen ja hermorakenteiden vapautuksen pitkäaikaistulokset sekä toipumisennusteeseen vaikuttavat tekijät. Ensimmäisen osajulkaisun tulokset osoittivat, että lantiorenkaan etuosaan kiinnitettävä ulkoinen kiinnityslaite (externi fiksaatiolaite) ei ollut luotettava, eikä sillä voitu taata asianmukaista murtuman paikalleen asettamista ja hyvää lopputulosta vaikeimmissa B- ja C-tyypin murtumissa. Toinen osajulkaisu osoitti, että vuotavien lantionmurtumien kohdalla huonoin ennuste liittyi lantiovammoihin, joissa valtimoiden varjoainekuvauksessa (angiografiassa) todettiin lantion päävaltimon (arteria iliaca interna tai externa) repeämä tai useampia samanaikaisia pienempien valtimosuonten repeämiä. Embolisaatio osoittautui luotettavaksi hoitomenetelmäksi ja kaikki valtimoperäiset vuodot pystyttiin tukkimaan. Kriittisessä vuototilanteessa, jossa angiografiassa todetaan useita vuotokohtia lantion valtimoissa, tulee embolisaatio suorittaa ei-selektiivisesti siten, että lantion aluetta suonittava päävaltimo (arteria iliaca interna) tukitaan välittömästi. Näin vuoto saadaan nopeammin hallintaan ja potilaan selviytymisennuste paranee. C-tyypin lantionmurtumien sisäinen kiinnitysmenetelmä, lantiorenkaan kiinnitys edestä levyin sekä takaa ruuvein tai levyin, osoittautui luotettavaksi (kolmas osajulkaisu). Saavutettu asento säilyi seurannassa erinomaisena tai hyvänä 90%:ssa tapauksista. Leikkauksessa saavutettu murtuman hyvä asento korreloi hyvään neurologiseen toipumiseen ja toiminnalliseen tulokseen. Epäanatominen tulos siten, että murtuman lopullinen siirtymä oli yli 5 mm, ennusti huonompaa toiminnallista lopputulosta. Merkittävin toimintakykyä rajoittava tekijä aiheutui lantion alueen hermopunosvauriosta. Tulokset tukevat käsitystä, jonka mukaan C-tyypin vammoissa tulee korjata ja kiinnittää kaikki murtumat lantiorenkaan etu- ja takaosassa, jolloin saavutetaan parempi anatominen tulos ja samalla parempi lantiorenkaan kokonaistukevuus. Ristiluun H-tyypin murtuma, johon liittyy selkärangan ja lantiorenkaan irtoama toisistaan, on harvinainen lantion takaosan alueen vammakokonaisuus. Neljännessä osajulkaisussa käytetty lannerangan ja lantion välinen kiinnitysmenetelmä (lumbopelvinen kiinnitys) osoittautui luotettavaksi. Lantiohermopunoksen (alaraajojen osittainen halvaus) ja ristiluuhermojen vammat (ns. kauda equina syndrooma) ovat tähän vammatyyppiin liittyen yleisiä. Hermovaurion korjaantuminen ja kokonaistoipumisen ennuste oli riippuvainen ristiluun poikittaisen murtuman siirtymän asteesta. Hermovaurio oli vaikeampiasteinen ja toipumistulos huonompi, mikäli siirtymä ensimmäisessä kuvauksessa oli yli ristiluun paksuuden, kun tuloksia verrattiin siihen potilasryhmään, jolla siirtymä oli osittainen. Hyvä leikkauksessa saavutettu asento kaikissa ristiluun murtumalinjoissa oli yhteydessä parempaan toipumisennusteeseen. Systemaattisella tutkimisella sekä määrätietoisella ja vaikuttavalla hoidolla voidaan vähentää lantiorenkaan murtumiin liittyvää kuolleisuutta, sairastavuutta ja pysyvää vammautumista