Search tips
Search criteria

Results 1-25 (1462216)

Clipboard (0)

Related Articles

1.  Management pitfalls of fractured neck of femur in osteogenesis imperfecta 
Fractured neck of femur in osteogenesis imperfecta is rarely reported. Its management is always difficult because of bone fragility and the outcome is not well known. We, therefore, aimed to study the management pitfalls in this group of patients.
We retrospectively reviewed five cases of fractured neck of femur in four patients treated in our hospital between 2006 and 2009. The demographic data, mode of injury, fracture configuration, treatment, complications, clinical and radiological outcome were reviewed.
According to the Sillence classification, one patient was type I, two were type III and one was type IV. There were two children (aged 8 and 15 years) and two adults (aged 21 and 22 years), with the 8 year-old girl suffering from hip fracture on different sides in two accidents. All five hip fractures were the result of low-energy injury and were associated with other fractures. Two undisplaced fractures required intra-operative fluoroscopic confirmation to demonstrate movement at the fracture site. The interval between the injury and fixation ranged from 6 h to 3 days. One hip required secondary surgery to openly reduce the fracture due to inadequate primary fixation and reduction. Two hips were fixed with paediatric dynamic hip screws and three hips were fixed with cannulated screws. All patients were immobilised in hip spica for 6 weeks. The average follow-up was 4 years (3–5 years). All patients had satisfactory union and none of them developed radiological evidence of avascular necrosis at the latest follow-up. All patients returned to their pre-injury functional level.
Fractured neck of femur is rare given the high prevalence of long bone fractures in osteogenesis imperfecta. They all have characteristic associated fractures of the extremity at the time of injury and neck of femur fractures could be easily missed. Fracture fixation is a great challenge to the orthopaedic surgeons because of the small size of the patients, poor bone quality with suboptimal imaging intra-operatively and compromised purchase of fixation devices. The choice of implants should be determined by the size of the patients and the presence of prior instrumentation close to the hip joint.
PMCID: PMC3672462  PMID: 24432078
Osteogenesis imperfecta; Fractured neck of femur; Operative challenge
2.  Fracture Surgery of the extremities with the intra-operative use of 3D-RX: A randomized multicenter trial (EF3X-trial) 
Posttraumatic osteoarthritis can develop after an intra-articular extremity fracture, leading to pain and loss of function. According to international guidelines, anatomical reduction and fixation are the basis for an optimal functional result. In order to achieve this during fracture surgery, an optimal view on the position of the bone fragments and fixation material is a necessity. The currently used 2D-fluoroscopy does not provide sufficient insight, in particular in cases with complex anatomy or subtle injury, and even an 18-26% suboptimal fracture reduction is reported for the ankle and foot. More intra-operative information is therefore needed.
Recently the 3D-RX-system was developed, which provides conventional 2D-fluoroscopic images as well as a 3D-reconstruction of bony structures. This modality provides more information, which consequently leads to extra corrections in 18-30% of the fracture operations. However, the effect of the extra corrections on the quality of the anatomical fracture reduction and fixation as well as on patient relevant outcomes has never been investigated.
The objective of this study protocol is to investigate the effectiveness of the intra-operative use of the 3D-RX-system as compared to the conventional 2D-fluoroscopy in patients with traumatic intra-articular fractures of the wrist, ankle and calcaneus. The effectiveness will be assessed in two different areas: 1) the quality of fracture reduction and fixation, based on the current golden standard, Computed Tomography. 2) The patient-relevant outcomes like functional outcome range of motion and pain. In addition, the diagnostic accuracy of the 3D-RX-scan will be determined in a clinical setting and a cost-effectiveness as well as a cost-utility analysis will be performed.
In this protocol for an international multicenter randomized clinical trial, adult patients (age > 17 years) with a traumatic intra-articular fracture of the wrist, ankle or calcaneus eligible for surgery will be subjected to additional intra-operative 3D-RX. In half of the patients the surgeon will be blinded to these results, in the other half the surgeon may use the 3D-RX results to further optimize fracture reduction. In both randomization groups a CT-scan will be performed postoperatively. Based on these CT-scans the quality of fracture reduction and fixation will be determined. During the follow-up visits after hospital discharge at 6 and 12 weeks and 1 year postoperatively the patient relevant outcomes will be determined by joint specific, health economic and quality of life questionnaires. In addition a follow up study will be performed to determine the patient relevant outcomes and prevalence of posttraumatic osteoarthritis at 2 and 5 years postoperatively.
The results of the study will provide more information on the effectiveness of the intra-operative use of 3D-imaging during surgical treatment of intra-articular fractures of the wrist, ankle and calcaneus. A randomized design in which patients will be allocated to a treatment arm during surgery will be used because of its high methodological quality and the ability to detect incongruences in the reduction and/or fixation that occur intra-operatively in the blinded arm of the 3D-RX. An alternative, pragmatic design could be to randomize before the start of the surgery, then two surgical strategies would be compared. This resembles clinical practice better, but introduces more bias and does not allow the assessment of incongruences that would have been detected by 3D-RX in the blinded arm.
Trial registration
Dutch Trial Register NTR 1902
PMCID: PMC3152540  PMID: 21733185
Fracture; Wrist; Ankle; Calcaneus; Intra-operative imaging; 2D-fluoroscopy; 3D-imaging; Conebeam-CT; 3D-RX
3.  Comparing radiation exposure during percutaneous vertebroplasty using one- vs. two-fluoroscopic technique 
Percutaneous vertebroplasty (PV) requires relatively lengthy fluoroscopic guidance, which might lead to substantial radiation exposure to patients or operators. The two-fluoroscopic technique (two-plane radiographs obtained using two fluoroscopes) during PV can provide simultaneous two-planar projections with reducing operative time. However, the two-fluoroscopic technique may expose the operator or patient to increased radiation dose. The aim of this study was to quantify the amount of radiation exposure to the patient or operator that occurs during PV using one- vs. two-fluoroscopic technique.
Two radiation dosimeters were placed on the right flank of each patient and on the upper sternum of each operator during 26 single-level PV procedures by one senior surgeon. The use of two-fluoroscopic technique (13 patients) and one-fluoroscopic technique (13 patients) were allocated in a consecutive and alternative manner. The operative time and mean radiation dose to each patient and operator were monitored and compared between groups.
Mean radiation dose to the patient was 1.97 ± 1.20 mSv (95% CI, 0.71 to 3.23) for the one-fluoroscopic technique group vs. 0.95 ± 0.34 mSv (95% CI, 0.85 to 1.23) for the two-fluoroscopic technique group (P =0.031). Mean radiation dose to the operator was 0.27 ± 0.12 mSv (95% CI, 0.17–0.56) for the one-fluoroscopic technique group vs. 0.25 ± 0.14 mSv (95% CI, 0.06–0.44) for the two-fluoroscopic technique group (P = 0.653). The operative time was significantly different between groups: 47.15 ± 13.48 min (range, 20–75) for the one-fluoroscopic technique group vs. 36.62 ± 8.42 min (range, 21–50) for the two-fluoroscopic technique group (P =0.019).
Compared to the one-fluoroscopic technique, the two-fluoroscopic technique used during PV provides not only shorter operative times but also reduces the radiation exposure to the patient. There was no significant difference between the two techniques with regards to radiation exposure to the operator.
PMCID: PMC3557160  PMID: 23339360
Vertebral compression fracture; Osteoporosis; Vertebroplasty; Radiation dose
4.  Surgeons' Exposure to Radiation in Single- and Multi-Level Minimally Invasive Transforaminal Lumbar Interbody Fusion; A Prospective Study 
PLoS ONE  2014;9(4):e95233.
Although minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) has widely been developed in patients with lumbar diseases, surgeons risk exposure to fluoroscopic radiation. However, to date, there is no studies quantifying the effective dose during MIS-TLIF procedure, and the radiation dose distribution is still unclear. In this study, the surgeons' radiation doses at 5 places on the bodies were measured and the effective doses were assessed during 31 consecutive 1- to 3-level MIS-TLIF surgeries. The operating surgeon, assisting surgeon, and radiological technologist wore thermoluminescent dosimeter on the unshielded thyroid, chest, genitals, right middle finger, and on the chest beneath a lead apron. The doses at the lens and the effective doses were also calculated. Mean fluoroscopy times were 38.7, 53.1, and 58.5 seconds for 1, 2, or 3 fusion levels, respectively. The operating surgeon's mean exposures at the lens, thyroid, chest, genitals, finger, and the chest beneath the shield, respectively, were 0.07, 0.07, 0.09, 0.14, 0.32, and 0.05 mSv in 1-level MIS-TLIF; 0.07, 0.08, 0.09, 0.18, 0.34, and 0.05 mSv in 2-level; 0.08, 0.09, 0.14, 0.15, 0.36, and 0.06 mSv in 3-level; and 0.07, 0.08, 0.10, 0.15, 0.33, and 0.05 mSv in all cases. Mean dose at the operating surgeon's right finger was significantly higher than other measurements parts (P<0.001). The operating surgeon's effective doses (0.06, 0.06, and 0.07 mSv for 1, 2, and 3 fusion levels) were low, and didn't differ significantly from those of the assisting surgeon or radiological technologist. Revision MIS-TLIF was not associated with higher surgeons' radiation doses compared to primary MIS-TLIF. There were significantly higher surgeons' radiation doses in over-weight than in normal-weight patients. The surgeons' radiation exposure during MIS-TLIF was within the safe level by the International Commission on Radiological Protection's guidelines. The accumulated radiation exposure, especially to surgeon's hands, should be carefully monitored.
PMCID: PMC3988176  PMID: 24736321
5.  Establishing the radiation risk from fluoroscopic-assisted arthroscopic surgery of the hip 
International Orthopaedics  2012;36(9):1803-1806.
The purpose of the study was to quantify patient exposure to ionising radiation during fluoroscopic-assisted arthroscopic surgery of the hip, establish a risk profile of this exposure, and reassure patients of radiation safety during the procedure.
We retrospectively analysed the dose area products for 50 consecutive patients undergoing arthroscopic hip surgery by an experienced hip arthroscopic surgeon. The effective dose and organ dose were derived using a Monte Carlo program.
The mean total fluoroscopy time was 1.10 minutes and the mean dose area product value was 297.2 cGycm2. We calculated the entrance skin dose to be 52 mGy to the area where the beam was targeted (81 cm2). The mean effective dose for intra-operative fluoroscopy was 0.33 mSv, with a SD of 0.90 Sv.
This study confirms that fluoroscopic-assisted arthroscopic surgery of the hip is safe with a low maximum radiation dose and supports its continued use in preference to alternative imaging modalities.
PMCID: PMC3427451  PMID: 22588691
6.  Ipsilateral femoral neck and shaft fractures: a retrospective analysis of two treatment methods 
No consensus exists regarding the optimal treatment of ipsilateral femoral neck and shaft fractures. The three major issues related to these fractures are the optimal timing of surgery, which fracture to stabilize first, and the optimal implant to use. In an effort to find answers to these three key issues, we report our experience of managing 27 patients with ipsilateral femoral neck and shaft fractures by using two different treatment methods, i.e., reconstruction-type intramedullary nailing and various plate combinations.
Materials and methods
We divided patients into two groups. Group I included 15 patients (13 males and 2 females) who were operated with cancellous lag screws or dynamic hip screws (DHS) for fractured neck and compression plate fixation for fractured shaft of the femur. Group II included 12 patients (11 males and 1 female) who were operated with reconstruction-type intramedullary nailing.
Mean age was 33.2 and 37.9 years in group I and II, respectively. Mean delay in surgery was 5.9 and 5.4 days in group I and II, respectively. Average union time for femoral neck fracture in groups I and II were 15.2 and 17.1 weeks, respectively; and for shaft fracture these times were 20.3 and 22.8 weeks, respectively. There were 13 (86.6%) good, 1 (6.7%) fair and 1 (6.7%) poor functional results in group I. There were 10 (83.3%) good, 1 (8.3%) fair and 1 (8.3%) poor functional results in group II.
Both of the treatment methods used in the present study achieved satisfactory functional outcome in these complex fractures. Fixation with plate for shaft and screws or DHS for hip is easy from a technical point of view. Choice of the treatment method should be dictated primarily by the type of femoral neck fracture and the surgeon’s familiarity with the treatment method chosen. The femoral neck fracture should preferably be stabilized first, and a delay of 5–6 days does not affect the ultimate functional outcome.
PMCID: PMC2656981  PMID: 19384610
Reconstruction nailing; Plating; Ipsilateral femoral neck and shaft fracture; Dynamic hip screw; Lag screw
7.  Management of Hip Fractures in Lateral Position without a Fracture Table 
Hip fracture Management in supine position on a fracture table with biplane fluoroscopic views has some difficulties which leads to prolongation of surgery and increasing x- rays' dosage.
The purpose of this study was to report the results and complications of hip fracture management in lateral position on a conventional operating table with just anteroposterior fluoroscopic view.
40 hip fractures (31 trochanteric and 9 femoral neck fractures) were operated in lateral position between Feb 2006 and Oct 2012. Age, gender, fracture classification, operation time, intra-operation blood loss, reduction quality, and complications were extracted from patients' medical records. The mean follow-up time was 30.78±22.73 months (range 4-83).
The mean operation time was 76.50 ± 16.88 min (range 50 - 120 min).The mean intra-operative blood loss was 628.75 ± 275.00 ml (range 250-1300ml). Anatomic and acceptable reduction was observed in 95%of cases. The most important complications were malunion (one case in trochanteric group), avascular necrosis of femoral head and nonunion (each one case in femoral neck group).
It sounds that reduction and fixation of hip fractures in lateral position with fluoroscopy in just anteroposterior view for small rural hospitals may be executable and probably safe.
PMCID: PMC4225021  PMID: 25386577
Fluoroscopy; Fracture table; Hip fracture; Lateral position; Trauma
8.  Hip Fracture Incidence in Relation to Age, Menopausal Status, and Age at Menopause: Prospective Analysis 
PLoS Medicine  2009;6(11):e1000181.
Using data from the UK Million Women Study, Emily Banks and colleagues investigate the relationships between the incidence of hip fracture and a woman's age, menopausal status, and age at menopause.
Bone mineral density is known to decrease rapidly after the menopause. There is limited evidence about the separate contributions of a woman's age, menopausal status and age at menopause to the incidence of hip fracture.
Methods and Findings
Over one million middle-aged women joined the UK Million Women Study in 1996–2001 providing information on their menopausal status, age at menopause, and other factors, which was updated, where possible, 3 y later. All women were registered with the UK National Health Service (NHS) and were routinely linked to information on cause-specific admissions to NHS hospitals. 561,609 women who had never used hormone replacement therapy and who provided complete information on menopausal variables (at baseline 25% were pre/perimenopausal and 75% postmenopausal) were followed up for a total of 3.4 million woman-years (an average 6.2 y per woman). During follow-up 1,676 (0.3%) were admitted to hospital with a first incident hip fracture. Among women aged 50–54 y the relative risk (RR) of hip fracture risk was significantly higher in postmenopausal than premenopausal women (adjusted RR 2.22, 95% confidence interval [CI] 1.22–4.04; p = 0.009); there were too few premenopausal women aged 55 y and over for valid comparisons. Among postmenopausal women, hip fracture incidence increased steeply with age (p<0.001), with rates being about seven times higher at age 70–74 y than at 50–54 y (incidence rates of 0.82 versus 0.11 per 100 women over 5 y). Among postmenopausal women of a given age there was no significant difference in hip fracture incidence between women whose menopause was due to bilateral oophorectomy compared to a natural menopause (adjusted RR 1.20, 95% CI 0.94–1.55; p = 0.15), and age at menopause had little, if any, effect on hip fracture incidence.
At around the time of the menopause, hip fracture incidence is about twice as high in postmenopausal than in premenopausal women, but this effect is short lived. Among postmenopausal women, age is by far the main determinant of hip fracture incidence and, for women of a given age, their age at menopause has, at most, a weak additional effect.
Please see later in the article for the Editors' Summary
Editors' Summary
Anyone can break a hip but most hip fractures occur in elderly people. As people age, their bones gradually lose minerals and become less dense, which weakens the bones and makes them more susceptible to fracture. Because women lose bone density faster than men as they age and because women constitute the majority of the elderly, three-quarters of hip fractures occur in women. Hip fractures can cause long-term health problems and premature death. Thus, although surgical repair of a broken hip usually only requires a hospital stay of about a week, a quarter of elderly people who were living independently before their fracture have to stay in a nursing home for at least a year after their injury and a fifth of elderly people who break a hip die within the year. Most hip fractures are caused by falls. Regular exercise to improve strength and balance combined with review of medicines (to reduce side effects and interactions), regular eye examinations, and the removal of fall hazards from the home can help to prevent hip fractures in elderly people.
Why Was This Study Done?
Bone density decreases very rapidly in women immediately after menopause—the time when menstruation permanently stops—and then continues to decrease more slowly with age. Most women have their menopause in their early 50s but menopause can occur in younger women. Early menopause is thought to be a risk factor for osteoporosis (thinning of the bones) and fractures later in life but little is known about how menopause influences hip fracture risk as women age. In this prospective study (a type of study in which a group of people is followed for several years to see whether they develop a particular condition), the researchers investigate the incidence of hip fractures in relation to age, menopausal status, and age at menopause among the participants of the Million Women Study. This study, which recruited 1.3 million women aged 50–64 years who attended UK breast cancer screening clinics between 1996 and 2001, has been investigating how reproductive and lifestyle factors affect women's health.
What Did the Researchers Do and Find?
At enrollment and three years later, the study participants provided information about their menopausal status and other health and lifestyle factors likely to affect their fracture risk. From these data, the researchers identified more than half a million women who had never used hormone replacement therapy (which reduces fracture risk) and who had given complete information about their menopausal status. They then looked for statistical associations between the occurrence of a first hip fracture in these women over the next few years and their age, menopausal status, and age at menopause. Among women aged 50–54 years, postmenopausal women were twice as likely to have a hip fracture as premenopausal women. Among postmenopausal women, the incidence of hip fractures increased steeply with age and was seven times higher in 70–74-year olds than in 50–54-year olds. Women who had their menopause before age 45 had a slightly increased risk of hip fracture but any effect of age at menopause on the risk of hip fracture was small compared to the effect of age itself, and the slightly increased risk may have been due to other factors that could not be fully accounted for in the analysis.
What Do These Findings Mean?
These findings indicate that around the time of menopause, although hip fractures are rare, the risk of a fracture in postmenopausal women is twice that in premenopausal women. The findings also show that among postmenopausal women, age is the major determinant of hip fracture risk and that for women of a given age, their age at menopause has little effect on hip fracture risk. Women attending breast cancer screening clinics and completing questionnaires about their health may not be representative of the general population. Furthermore, these findings rely on women self-reporting their menopausal status accurately. Nevertheless, the results of this study suggest that clinicians advising women about hip fracture prevention should probably base their advice on the woman's age and on age-related factors such as frailty rather than on factors related to menopause. Clinicians can also now reassure elderly women who had an early menopause that their risk of hip fracture is unlikely to be higher than that of similar women who had a later menopause.
Additional Information
Please access these Web sites via the online version of this summary at
The American Academy of Orthopaedic Surgeons has detailed information about hip fractures
The US National Institute of Arthritis and Muscoloskeletal and Skin Diseases has an interactive feature called “Check up on your bones and provides detailed information about osteoporosis, including advice on fall prevention
The US Centers for Disease Control and Prevention has a fact sheet about hip fractures among older adults
MedlinePlus has links to resources about hip fracture, osteoporosis, and menopause (in English and Spanish)
More information on the Million Women Study is available
PMCID: PMC2766835  PMID: 19901981
9.  Exposure of the surgeon to radiation during surgery 
International Orthopaedics  1998;22(3):153-156.
Exposure to radiation over many years increases the incidence of cataracts and promotes the development of carcinoma of the thyroid gland. A prospective study of 24 operative procedures involving minimal invasive techniques and fluoroscopic guidance was undertaken in order to measure the radiation exposure to the primary surgeon. The study was conducted during 8 K-wire osteosyntheses in fractures of the distal radius, 8 closed interlocking intramedullary nailings in fractures of the femur and 8 internal fixator procedures, with or without posterior autogenic transpedicular bone grafting, in fractures of the lumbar spine. Radiation was monitored with the use of high sensitive thermoluminescent dosimeters. Fluoroscopy was necessary during the procedures, with exposure times ranging from 55 s to 12 min 35 s. The radiation dose received per procedure ranged from 0.6–259.3 μSv and was well within the dose limits set by German law.
PMCID: PMC3619589  PMID: 9728306
10.  Fluoroscopic Radiation Exposure during Percutaneous Kyphoplasty 
The author measured levels of fluoroscopic radiation exposure to the surgeon's body based on the different beam directions during kyphoplasty.
This is an observational study. A series of 84 patients (96 vertebral bodies) were treated with kyphoplasty over one year. The patients were divided into four groups based on the horizontal and vertical directions of the X-Ray beams. We measured radiation exposure with the seven dosimetry badges which were worn by the surgeon in each group (total of 28 badges). Twenty-four procedures were measured in each group. Cumulative dose and dose rates were compared between groups.
Fluoroscopic radiation is received by the operator in real-time for approximately 50% (half) of the operation time. Thyroid protectors and lead aprons can block radiation almost completely. The largest dose was received in the chest irrespective of beam directions. The lowest level of radiation were received when X-ray tube was away from the surgeon and beneath the bed (dose rate of head, neck, chest, abdomen and knee : 0.2986, 0.2828, 0.9711, 0.8977, 0.8168 mSv, respectively). The radiation differences between each group were approximately 2.7-10 folds.
When fluoroscopic guided-KP is performed, the X-Ray tube should be positioned on the opposite side of the operator and below the table, otherwise the received radiation to the surgeon's body would be 2.7-10 times higher than such condition.
PMCID: PMC3070893  PMID: 21494361
Kyphoplasty; Radiation exposure; Fluoroscopic guidance; Dosimetry; Radiation safety; Fluoroscopy
11.  Expandable self-locking nail in the management of closed diaphyseal fractures of femur and tibia 
Indian Journal of Orthopaedics  2009;43(3):264-270.
Intramedullary fixation is the treatment of choice for closed diaphyseal fractures of femur and tibia. The axial and rotational stability of conventional interlocking nails depends primarily on locking screws. This method uses increased operating time and increased radiation exposure. An intramedullary implant that can minimize these disadvantages is obviously better. Expandable intramedullary nail does not rely on interlocking screws and achieves axial and rotational stability on hydraulic expansion of the nail. We analyzed 32 simple fractures of shaft of femur and tibia treated by self-locking expandable nail.
Materials and Methods:
Intramedullary fixation was done by using self-locking, expandable nail in 32 patients of closed diaphyseal fractures of tibia (n = 10) and femur (n = 22). The various modes of injury were road traffic accidents (n = 21), fall from height (n = 8), simple fall (n = 2), and pathological fracture (n = 1). Among femoral diaphyseal fractures 16 were males and six females, average age being 33 yrs (range, 18- 62 yrs). Seventeen patients had AO type A (A1 (n = 3), A2 (n = 4), A3 (n = 10)) and 5 patients had AO type B (B1 (n = 2), B2 (n = 2), B3 (n = 1)) fractures. Eight patients having tibial diaphyseal fractures were males and two were females; average age was 29.2 (range, 18- 55 yrs). Seven were AO type A (A1 (n = 2), A2 (n = 3), A3 (n = 2)) and three were AO type B (B1 (n = 1), B2 (n = 1), and B3 (n = 1)). We performed closed (n = 27) or open reduction (n = 5) and internal fixation with expandable nail to stabilize these fractures. The total radiation exposure during surgery was less as no locking screws were required. Early mobilisation and weight-bearing was started depending on fracture personality and evidences of healing. Absence of localised tenderness and pain on walking was considered clinical criteria for union, radiographic criteria of union being continuity in at least in three cortices in both AP and lateral views. Patients were followed for at least one year.
The average operative time was 90 min (range, 55-125 min) for femoral fractures and 53 min (range, 25-115 min) for tibial fractures. Radiation exposure was minimum, average being 84 seconds (range, 54-132) for femoral fractures and 54 seconds (range, 36-78) for tibial fractures. All fractures healed, but few had complications, such as infection (one case with tibial fracture) bent femoral nail with malunion (n = 1), and delayed union (n = 3; 2 cases in femur and 1 case in tibia). Mean time of union was 5.1 months (range, 4-10½ months) for femoral fractures and 4.8 months (range, 3-9 months) for tibial fractures.
We found the nail very easy to use with effective fixation in AO type A and B fractures in our setting. Less surgical time is required with minimum complications. The main advantage of the expandable nail is that if affords. satisfactory axial, rotatory, and bending stability with decreased radiation exposure to operating staff and the patient.
PMCID: PMC2762176  PMID: 19838349
Diaphyseal fracture femur; diaphysial fracture tibia; expandable nail; self-locking nail; radiation risk
12.  Osteogenic Protein-1 for Long Bone Nonunion 
Executive Summary
To assess the efficacy of osteogenic protein-1 (OP-1) for long bone nonunion.
Clinical Need
Although most fractures heal within a normal period, about 5% to 10% do not heal and are classified as delayed or nonunion fractures. Nonunion and segmental bone loss after fracture, reconstructive surgery, or lesion excision can present complex orthopedic problems, and the multiple surgical procedures often needed are associated with patient morbidity and reduced quality of life.
Many factors contribute to the pathogenesis of a delayed union or nonunion fractures, including deficiencies of calcium, vitamin D, or vitamin C, and side effects of medications such as anticoagulants, steroids, some anti-inflammatory drugs, and radiation. It has been shown that smoking interferes with bone repair in several ways.
Incidence of Nonunion and Delayed Union Cases
An estimated 5% to 10% of fractures do not heal properly and go on to delayed union or nonunion. If this overall estimate of incidence were applied to the Ontario population1, the estimated number of delayed union or nonunion in the province would be between 3,863 and 7,725.
Treatment of Nonunion Cases
The treatment of nonunion cases is a challenge to orthopedic surgeons. However, the basic principle behind treatment is to provide both mechanical and biological support to the nonunion site.
Fracture stabilization and immobilization is frequently used with the other treatment modalities that provide biological support to the fractured bone. Biological support includes materials that could be served as a source of osteogenic cells (osteogenesis), a stimulator of mesenchymal cells (osteoinduction), or a scaffold-like structure (osteoconduction).
The capacity to heal a fracture is a latent potential of the stromal stem cells, which synthesize new bone. This process has been defined as osteogenesis. Activation of the stem cells to initiate osteogenic response and to differentiate into bone-forming osteoblasts is called osteoinduction. These 2 properties accelerate the rate of fracture healing or reactivate the ineffective healing process. Osteoconduction occurs when passive structures facilitate the migration of osteoprogenitor cells, the perivascular tissue, and capillaries into these structures.
Bone Grafts and Bone Graft Substitutes
Bone graft and bone graft substitutes have one or more of the following components:
Undifferentiated stem cells
Growth factors
Structural lattice
Undifferentiated stem cells are unspecialized, multipotential cells that can differentiate into a variety of specialized cells. They can also replicate themselves. The role of stem cells is to maintain and repair the tissue in which they are residing. A single stem cell can generate all cell types of that tissue. Bone marrow is a source of at least 2 kinds of stem cells. Hematopoietic stem cells that form all types of blood cells, and bone marrow stromal stem cells that have osteogenic properties and can generate bone, cartilage, and fibrous tissue.
Bone marrow has been used to stimulate bone formation in bone defects and cases of nonunion fractures. Bone marrow can be aspirated from the iliac crest and injected percutaneously with fluoroscopic guidance into the site of the nonunion fracture. The effectiveness of this technique depends on the number and activity of stem cells in the aspirated bone marrow. It may be possible to increase the proliferation and speed differentiation of stem cells by exposing them to growth factor or by combining them with collagen.
Many growth factors and cytokines induced in response to injury are believed to have a considerable role in the process of repair. Of the many bone growth factors studied, bone morphogenetics (BMPs) have generated the greatest attention because of their osteoinductive potential. The BMPs that have been most widely studied for their ability to induce bone regeneration in humans include BMP-2 and BMP-7 (osteogenic protein). Human osteogenic protein-1 (OP-1) has been cloned and produced with recombinant technology and is free from the risk of infection or allergic reaction.
The structural lattice is osteoconductive; it supports the ingrowth of developing capillaries and perivascular tissues. Three distinct groups of structural lattice have been identified: collagen, calcium sulphate, and calcium phosphate. These materials can be used to replace a lost segment of bone.
Grafts Used for Nonunion
Autologous bone graft is generally considered the gold standard and the best material for grafting because it contains several elements that are critical in promoting bone formation, including osteoprogenitor cells, the matrix, and bone morphogenetic proteins. The osteoconductive property of cancellous autograft is related to the porosity of bone. The highly porous, scaffold-like structure of the graft allows host osteoblasts and host osteoprogenitor cells to migrate easily into the area of the defect and to begin regeneration of bone. Sources of cancellous bone are the iliac crest, the distal femur, the greater trochanter, and the proximal tibia. However, harvesting the autologous bone graft is associated with postoperative pain at the donor site, potential injury to the surrounding arteries, nerves, and tissues, and the risk of infection. Thus the development of synthetic materials with osteoconductive and osteoinductive properties that can eliminate the need for harvesting has become a major goal of orthopedic research.
Allograft is the graft of tissue between individuals who are of the same species but are of a disparate genotype. Allograft has osteoconductive and limited osteoinductive properties. Demineralized bone matrix (DBM) is human cortical and cancellous allograft. These products are prepared by acid extraction of allograft bone, resulting in the loss of most of the mineralized component while collagen and noncollagenous proteins, including growth factors, are retained. Figures 1 to 5 demonstrate the osteogenic, osteoinduction, and osteoconduction properties of autologous bone graft, allograft, OP-1, bone graft substitutes, and bone marrow.
Autologous Bone Graft
Osteogenic Protein-1
Allograft bone and Demineralized Bone Matrix
Bone Graft Substitutes
Autologous Bone Marrow Graft
New Technology Being Reviewed: Osteogenic Protein-1
Health Canada issued a Class IV licence for OP-1 in June 2004 (licence number 36320). The manufacturer of OP-1 is Stryker Biotech (Hapkinton, MA).
The United States Food and Drug Administration (FDA) issued a humanitarian device exemption for the application of the OP-1 implant as an “alternative to autograft in recalcitrant long bone nonunions where use of autograft is unfeasible and alternative treatments have failed.” Regulatory agencies in Europe, Australia, and New Zealand have permitted the use of this implant in specific cases, such as in tibial nonunions, or in more general cases, such as in long bone nonunions.
According to the manufacturer, OP-1 is indicated for the treatment of long bone nonunions. It is contraindicated in the patient has a hypersensitivity to the active substance or collagen, and it should not be applied at the site of a resected tumour that is at or near the defect or fracture. Finally, it should not be used in patients who are skeletally immature (< 18 years of age), or if there is no radiological evidence of closure of epiphysis.
Review Strategy
To summarize the safety profile and effectiveness of OP-1 in the treatment of cases of long bone nonunion and bone defects
To compare the effectiveness and cost effectiveness of OP-1 in the treatment of long bone nonunions and bone defects with the alternative technologies, particularly the gold standard autologous bone graft.
Literature Search
International Network of Agencies for Health Technology Assessments (INAHTA), the Cochrane Database of Systematic Reviews and the CCTR (formerly Cochrane Controlled Trials Register) were searched for health technology assessments. MEDLINE, EMBASE, Medline In Process and Other Non-Indexed Citations were searched from January 1, 1996 to January 27, 2004 for studies on OP-1. The search was limited to English-language articles and human studies. The search yielded 47 citations. Three studies met inclusion criteria (2 RCTs and 1 Ontario-based study presented at an international conference.
Summary of Findings
Friedlaender et al. conducted a prospective, randomized, partially blinded clinical trial on the treatment tibial nonunions with OP-1. Tibial nonunions were chosen for this study because of their high frequency, challenging treatment requirements, and substantial morbidity. All of the nonunions were at least 9 months old and had shown no progress toward healing over the previous 3 months. The patients were randomized to receive either treatment with autologous bone grafting or treatment with OP-1 in a type-1 collagen carrier. Both groups received reduction and fixation with an intramedullary rod. Table 1 summarizes the clinical outcomes of this study.
Outcomes in a Randomized Clinical Trial on Tibial Nonunions: Osteogenic Protein-1 versus Autologous Bone Grafting
Clinical success was defined as full weight-bearing, loss of severe pain at the fracture site on weight-bearing, and no further surgical treatment to enhance fracture repair.
The results of this study demonstrated that recombinant OP-1 is associated with substantial clinical and radiographic success for the treatment of tibial nonunions when used with intramedullary rod fixation. No adverse event related to sensitization was reported. Five per cent of the patients in the OP-1 group had circulating antibodies against type 1 collagen. Only 10% of the patients had a low level of anti-OP-1 antibodies, and all effects were transient. Furthermore, the success rate with the OP-1 implant was comparable with those achieved with autograft at 9 and 24 months follow-up. Eighty-two per cent of patients were successful at 24 months follow-up in both groups.
Statistically significant increased blood loss in the group treated with the autograft was observed (P = .049). Patients treated with autograft had longer operation and hospitalization times. All patients in the autograft group had pain at the donor site after surgery, and more than 80% judged their postoperative pain as moderate or severe. At their 6-month visit, 20% of the patients in the autograft group had persistent pain, mild or moderate in nature, at the donor site. This number fell to 13% at 12 months.
All patients in each of the groups had at least 1 adverse event that wasn’t serious, such as fever, nausea and vomiting, leg edema, discomfort, and bruising at the operative site. The incidence of these events was similar in both groups. Serious adverse events were observed in 44% of both groups, none of which were considered related to the OP-1 implant or autograft.
On the basis of this data, the FDA issued a humanitarian device exemption for the application of OP-1 implant as an alternative to autograft in recalcitrant long bone nonunions when the use of autograft is unfeasible and alternative treatments have failed.
Study on Fibular Defects
Geesink et al. investigated the osteogenic activity of OP-1 by assessing its value in bridging fibular defects made at the time of tibial osteotomy for varus or valgus deformity of the knee. This study had 2 phases and included 12 patients in each phase. Each phase included 12 patients (6 in each group). Patients in the first phase received either DBM or were left untreated. Patients in the second phase received either OP-1 on collagen type-1 or collagen type-1 alone.
Radiological and Dual Energy X-ray Absorptiometry (DEXA) evaluation showed that in patients in whom the defect was left untreated, no formation of bone occurred. At 12 months follow-up, new bone formation with bridging occurred in 4 of the 6 patients in DMB group, and 5 of the 6 patients in OP-1 group. One patient in OP-1 group did not show any evidence of new bone formation at any point during the study.
Ontario Pilot Study
A prospective pilot study was conducted in Ontario, Canada to investigate the safety and efficacy of OP-1 for the treatment of recalcitrant long bone nonunions. The study looked at 15 patients with complex, recalcitrant, long bone nonunions whose previous treatment had failed. The investigators concluded that this bone graft substitute appears to be safe and effective in providing sufficient biological stimulation in difficult to treat nonunions. Results of a more complete study on 70 patients are ready for publication. According to the principal investigator, OP-1 was 90% effective in inducing bone formation and bone healing in this sample.
Alternative Technologies
The Medical Advisory Secretariat conducted a literature search from January 1, 2000 to February 28, 2005 to identify studies on nonunions/bone defects that had been treated with alternative technologies. A review of these studies showed that, in addition to the gold standard autologous bone marrow grafting, bone allografts, demineralized bone matrices, bone graft substitutes, and autologous bone marrow have been used for treatment of nonunions and bone defects. These studies were categorized according to the osteoinductive, osteoconductive, and osteogenesis properties of the technologies studied.
A review of these studies showed that bone allografts have been used mostly in various reconstruction procedures to restore the defect after excavating a bone lesion. Two studies investigated the effectiveness of DBM in healing fracture nonunions. Calcium phosphate and calcium sulphate have been used mostly for repair of bone defects.
Several investigators have looked at the use of autologous bone marrow for treatment of long bone nonunions. The results of these studies show that method of percutaneous bone marrow grafting is highly effective in the treatment of long bone nonunions. In a total of 301 fractures across all studies, 268 (89%) healed with a mean healing time of 2.5 to 8 months. This healing time as derived from these case series is less than the timing of the primary end point in Friedlaender’s study (9 months). Table 2 summarizes the results of these studies. Table 2 summarizes the results of these studies.
Studies that used Percutaneous Bone Marrow Grafting for Treatment of Nonunions
Economic Analysis
Based on annual estimated incidence of long-bone nonunion of 3,863 - 7,725, the annual hospitalization costs associated with this condition is between $21.2 and $42.3 million based on a unit cost of $5,477 per hospital separation. When utilized, the device, a single vial of OP-1, is approximately $5,000 and if adopted universally in Ontario, the total device costs would be in the range of $19.3 - $38.6 million annually. The physician fee for harvest, insertion of bone, or OP-1 is $193 and is $193 for autologous bone marrow transplantation. Total annual physician costs are expected to be in the range of from $0.7 million to $1.3 million per year. Expenditures associated with long-bone nonunion are unlikely to increase since incidence of long-bone nonunion is unlikely to change in the future. However, the rate of uptake of OP-1 could have a significant impact on costs if the uptake were large.
The use of OP-1 and autologous bone marrow transplantation may offset pain medication costs compared with those associated with autologous bone harvest given that the former procedures do not involve the pain associated with the bone harvest site. However, given that this pain is normally not permanent, the overall offset is likely to be small. There are likely to be smaller OHIP costs associated with OP-1 than bone-harvest procedures given that only 1, rather than 2, incisions are needed when comparing the former with the latter procedure. This offset could amount to between $0.3 million to $0.7 million annually.
No data on the cost-effectiveness of OP-1 is available.
PMCID: PMC3382627  PMID: 23074475
13.  Rotational Fluoroscopy Assists in Detection of Intra-Articular Screw Penetration During Volar Plating of the Distal Radius 
The Journal of hand surgery  2010;35(4):619-627.
Intra-articular screw penetration is one complication of volar plate fixation of distal radius fractures. This study was designed to determine the most utilized imaging techniques and views during volar plating of distal radius fractures and to evaluate surgeons’ ability to detect intra-articular screw placement on static fluoroscopic images and rotational fluoroscopy.
Active members of The American Society for Surgery of the Hand were polled regarding preferred imaging techniques (fluoroscopic versus cassette radiographs) and views (rotational fluoroscopy, static orthogonal/anatomic tilt/semi-pronated imaging) during volar plating of distal radius fractures. Following the survey, volar locking plates were applied to 30 cadaveric distal radii. A single screw intentionally penetrated the radiocarpal joint in half of the specimens (15 arms) and intentionally did not penetrate the radiocarpal joint in the other half. Imaging (standard posterior-anterior (PA) and lateral views, 11° tilt PA and 22° tilt lateral views, and two 360° fluoroscopy movies) was performed utilizing a custom jig. Five blinded surgeons reviewed randomized image sets evaluating for intra-articular screw placement. Receiver operating characteristic curves were constructed to compare the reliability of each fluoroscopic projection/movie.
Among 696 survey respondents, 88% exclusively utilized fluoroscopic imaging (without cassette radiographs) and nearly 66% preferred either tilt images or rotational fluoroscopy to detect intra-articular screw penetration. In our cadaveric model, rotational fluoroscopy provided the highest sensitivity (93%) and specificity (96%) for the detection of intra-articular screw penetration. Rotational fluoroscopy was significantly more reliable (p<0.01) than most images (standard lateral, 11° PA, 22° lateral, paired PA/lateral) and trended strongly toward better reliability for all remaining images (standard PA [p=0.07], paired 11° PA/22° lateral [p=0.08], 22° tilt fluoroscopy movie [p=0.11]).
Rotational fluoroscopy improves the surgeon’s ability to detect intra-articular screw penetration during volar plating of the distal radius. No combination of imaging allowed detection of all intra-articular screws. A high level of suspicion for intra-articular screw penetration should be maintained during volar plating of distal radial fractures.
Level of evidence
Unable to be determined according to guidelines
PMCID: PMC2854080  PMID: 20202762
complication; distal radius; fracture; fluoroscopy; volar plate
14.  Evaluation of osteosynthesis with dual fibular bone grafting for neglected femoral neck fractures☆ 
Femoral neck fractures in young adults is an unsolved problem and neglected femoral neck fractures presents more challenge to the orthopaedics surgeon if femoral head salvage is attempted. We reviewed the operative results of neglected femoral neck fractures in young adults with fixation with dual fibular bone grafting Purpose of study was evaluation of epidemiological, clinical, functional, rehabilitative outcome and complications in such patients.
Twentyeight patients in age group 18–50 years were operated having fracture neck femur by dual fibular bone grafting in the Department of Orthopaedics, S.N. Medical College, Agra in (May 2005–February 2008) and divided into two groups. Group A: comprised of 8 patients treated by dual fibular bone grafting alone and Group B: comprised of 18 patients treated by dual fibular bone grafting with single cancellous hip screw.
All the patients of the present series were having neglected intracapsular fracture, neck femur which were treated by dual fibular bone grafting with or without cancellous hip screw fixation. Majority of the patients had good to fair result according to Larson method with average time of union 16 weeks. All patients had useful range of movement at hip. Satisfactory union was achieved in all patients except two.
Double bone grafting is a simple and cost effective modality of treatment for late femoral neck fracture with good results. It is a stable and biological method of fixation with preservation of natural femoral head with fewer complications.
PMCID: PMC3880501
Fracture neck femur; Double fibular bone grafting; Neglected; Biological
15.  Radiographic union score for hip substantially improves agreement between surgeons and radiologists 
Despite the prominence of hip fractures in orthopedic trauma, the assessment of fracture healing using radiographs remains subjective. The variability in the assessment of fracture healing has important implications for both clinical research and patient care. With little existing literature regarding reliable consensus on hip fracture healing, this study was conducted to determine inter-rater reliability between orthopedic surgeons and radiologists on healing assessments using sequential radiographs in patients with hip fractures. Secondary objectives included evaluating a checklist designed to assess hip fracture healing and determining whether agreement improved when reviewers were aware of the timing of the x-rays in relation to the patients’ surgery.
A panel of six reviewers (three orthopedic surgeons and three radiologists) independently assessed fracture healing using sequential radiographs from 100 patients with femoral neck fractures and 100 patients with intertrochanteric fractures. During their independent review they also completed a previously developed radiographic checklist (Radiographic Union Score for Hip (RUSH)). Inter and intra-rater reliability scores were calculated. Data from the current study was compared to the findings from a previously conducted study where the same reviewers, unaware of the timing of the x-rays, completed the RUSH score.
The agreement between surgeons and radiologists for fracture healing was moderate for “general impression of fracture healing” in both femoral neck (ICC = 0.60, 95% CI: 0.42-0.71) and intertrochanteric fractures (0.50, 95% CI: 0.33-0.62). Using a standardized checklist (RUSH), agreement was almost perfect in both femoral neck (ICC = 0.85, 95% CI: 0.82-0.87) and intertrochanteric fractures (0.88, 95% CI: 0.86-0.90). We also found a high degree of correlation between healing and the total RUSH score using a Receiver Operating Characteristic (ROC) analysis, there was an area under the curve of 0.993 for femoral neck cases and 0.989 for intertrochanteric cases. Agreement within the radiologist group and within the surgeon group did not significantly differ in our analyses. In all cases, radiographs in which the time from surgery was known resulted in higher agreement scores compared to those from the previous study in which reviewers were unaware of the time the radiograph was obtained.
Agreement in hip fracture radiographic healing may be improved with the use of a standardized checklist and appears highly influenced by the timing of the radiograph. These findings should be considered when evaluating patient outcomes and in clinical studies involving patients with hip fractures. Future research initiatives are required to further evaluate the RUSH checklist.
PMCID: PMC3599458  PMID: 23442540
Hip fractures; Reliability; Fracture healing; Radiographs
16.  Radiation exposure during the lateral lumbar interbody fusion procedure and techniques to reduce radiation dosage 
Fluoroscopy is widely used in spine surgery to assist with graft and hardware placement. Previous studies have not measured radiation exposure to a surgeon during minimally invasive lateral lumbar spine surgery for single-level discectomy and interbody cage insertion. This study was performed to model and measure radiation exposure to a surgeon during spine surgery using the direct lateral lumbar procedure.
The study was performed using a mannequin substituting for the surgeon and a cadaver substituting for the patient. Radiation was measured with dosimeters attached to 6 locations on the mannequin using a OEC Medical Systems 9800 C-arm fluoroscope (OEC Medical Systems, Salt Lake City, Utah). Three different fluoroscopy setups were tested: a standard imaging setup, a standard setup using pulsed-mode fluoroscopy, and a reversed setup. The experiment was tested 5 times per setup, and the dosimeters’ values were recorded.
The highest amount of radiation exposure occurred when obtaining an anteroposterior view of the spine in the standard setup. Compared with the standard setup, the pulsed-mode setting decreased the radiation exposure to the mannequin by a factor of 6 times (P < .001). Compared with the standard setup, the reversed setup also decreased the radiation exposure to the mannequin by a factor of 6 times (P < .001) and it had the lowest amount of radiation exposure to the eye level (P < .001).
Care should be taken when one is obtaining an anteroposterior view of the lumbar spine during lateral lumbar procedures to limit radiation exposure. Radiation exposure to the surgeon can be greatly minimized by using either a pulsed imaging mode or the reversed setup. The reversed setup has the lowest amount of radiation exposure to the eye level.
PMCID: PMC4300901
17.  Difficulties encountered removing locked plates 
Locked plates are commonly used to obtain fixation in periarticular and comminuted fractures. Their use has also gained popularity in repairing fractures in osteoporotic bone. These plates provide stable fixation and promote biological healing. Over the last 3 years, we have used over 150 locked plates with varying success to fix periarticular fractures involving mainly the knee and ankle. In this study, we report our clinical experience and the difficulties encountered when removing locked plates in adult patients with a variety of indications including implant failure, infection, non-union and a palpable symptomatic implant.
A retrospective analysis was performed of patients enrolled prospectively into a database. Included in the study were 36 consecutive adult patients who each underwent the procedure of locked plate removal in a single inner city level 1 trauma centre. Data collected included primary indication for fixation, indication for implant removal, time of the implant in situ, grade of operating surgeon and difficulties encountered during the procedure.
Implant removal was associated with a complication rate of 47%. The major problems encountered were difficulty in removing the locked screws and the implant itself. A total of ten cold welded screws were found in eight cases. Removal was facilitated by high speed metal cutting burrs and screw removal sets in all but one case, where a decision was made to leave the plate in situ.
The majority of studies investigating implant removal and problems encountered in doing so report a relatively high complication rate. With the advent of locking plates and their growing popularity, difficulties are now being seen intra-operatively when removing them. There is a paucity of data, however, specifically directed at locking plate removal. We recommend that surgeons should be aware of the potential complications while removing locked plates. Fluoroscopic control and all available extra equipment (mainly metal cutting burrs and screw removal sets) should be available in theatre.
PMCID: PMC3954247  PMID: 23031770
Locked plates; Less invasive stabilisation system; Locking compression plate; Hardware removal; Complications; Cold welding
18.  Determinants of outcome in operatively and non-operatively treated Weber-B ankle fractures 
Treatment of ankle fractures is often based on fracture type and surgeon’s individual judgment. Literature concerning the treatment options and outcome are dated and frequently contradicting. The aim of this study was to determine the clinical and functional outcome after AO-Weber B-type ankle fractures in operatively and conservatively treated patients and to determine which factors influenced outcome.
Patients and methods
A retrospective cohort study in patients with a AO-Weber B-type ankle fracture. Patient, fracture and treatment characteristics were recorded. Clinical and functional outcome was measured using the Olerud–Molander Ankle Score (OMAS), the American Orthopaedic Foot and Ankle Society ankle-hindfoot score (AOFAS) and a Visual Analog Score (VAS) for overall satisfaction (range 0–10).
Eighty-two patients were treated conservatively and 103 underwent operative treatment. The majority was female. Most conservatively treated fractures were AO-Weber B1.1 type fractures. Fractures with fibular displacement (mainly AO type B1.2 and Lauge-Hansen type SER-4) were predominantly treated operatively. The outcome scores in the non-operative group were OMAS 93, AOFAS 98, and VAS 8. Outcome in this group was independently negatively affected by age, affected side, BMI, fibular displacement, and duration of plaster immobilization. In the surgically treated group, the OMAS, AOFAS, and VAS scores were 90, 97, and 8, respectively, with outcome negatively influenced by duration of plaster immobilization.
Treatment selection based upon stability and surgeon’s judgment led to overall good clinical outcome in both treatment groups. Reducing the cast immobilization period may further improve outcome.
PMCID: PMC3261401  PMID: 21959696
Ankle; Fracture; Outcome; Operative; Non-operative
19.  Improved Screw Placement for Slipped Capital Femoral Epiphysis (SCFE) using Robotically-Assisted Drill Guidance 
Slipped Capital Femoral Epiphysis (SCFE) is a common hip displacement condition in adolescents. In the standard treatment, the surgeon uses intra-operative fluoroscopic imaging to plan the screw placement and the drill trajectory. The accuracy, duration, and efficacy of this procedure are highly dependent on surgeon skill. Longer procedure times result in higher radiation dose, to both patient and surgeon. A robotic system to guide the drill trajectory might help to reduce screw placement errors and procedure time by reducing the number of passes and confirmatory fluoroscopic images needed to verify accurate positioning of the drill guide along a planned trajectory. Therefore, with the long-term goals of improving screw placement accuracy, reducing procedure time and intra-operative radiation dose, our group is developing an image-guided robotic surgical system to assist a surgeon with pre-operative path planning and intra-operative drill guide placement.
PMCID: PMC4205479  PMID: 25333154
Slipped Capital Femoral Epiphysis (SCFE); Robotically-assisted orthopedic surgery; Computer-aided intervention
20.  Fractures of the Femur. End Results* 
Melvin Starkey Henderson was born in St. Paul, Minnesota and received his early schooling there and in Winnipeg, Manitoba [4]. He received his undergraduate and medical degrees from the University of Toronto. He then interned in the City and County Hospital in his home town of St. Paul, and in 1907 went to work as an assistant with the founders of the recently formed Mayo Clinic, William James and Charles Horace Mayo. To further his training and evidently at the suggestion of the Mayo brothers, in 1911 Dr. Henderson went abroad to work under Sir Robert Jones in Liverpool and then Sir Harold Stiles in Edinburgh. He returned to organize and direct the section of orthopaedic surgery at the Mayo Clinic and spent his entire professional career there.
Dr. Henderson was involved in many national and international organizations, and was a founder and first President of the American Board of Orthopaedic Surgeons when it was established at the Kahler Hotel in Rochester, Minnesota, on June 5, 1934, after several previous organizational meetings [5]. Wickstrom [5], describing the organization of the Board, commented, “After all, in the opinion of the East coast establishment, Dr. Henderson (who was born in St. Paul, was educated in Canada, and had his beginning with the Mayo brothers as a clinical assistant riding a bicycle around Rochester, making house calls on the Mayo brothers’ patients) was a mere upstart.” However, at the time Dr. Henderson was 50 years old and had been President of the American Orthopaedic Association and Clinical Orthopaedic Society, as well as prominent in the American Medical Association and other organizations. Dr. Henderson was one of three of the first 15 AAOS Presidents (the other two being Drs. Philip D. Wilson and John C. Wilson, Sr.) who had a son who succeeded him as President. He was greatly respected for his organizational abilities, particularly at the Board, whose objectives were uncertain in the beginning and required sage guidance [5].
We reproduce here an article in which Dr. Henderson reviewed 222 consecutive cases of femur fractures, 165 of which had been referred late because of complications of fractures treated elsewhere (clearly, by 1921, the Mayo Clinic was a referral source for others) [2]. Followup could not have been easy at a time when patients often came from a distance and travel was difficult, but it was described when available and in 40 of the 57 recent fractures, Henderson reported 87.5% were “cured.” Of the 165 old fractures, he was able to trace 143 (87%), a remarkable figure even today. He reported 90% of the femoral neck fractures were cured by various sorts of nonsurgical (6 patients) or surgical reconstructive (39 patients) means; 85% of the femoral shaft fractures were cured by either nonoperative (29 patients) or operative (69 patients) means. While he did not use the sort of outcomes we use today (the earliest orthopaedic outcome instruments were not introduced for four more decades: by Carroll B. Larson in 1963 [3] and William H. Harris in 1969 [1]), we can only presume Henderson meant union was achieved when patients were “cured” since nonunion or malunion would not have likely produced good results. That being the case, his rate of union was remarkable and would be enviable today in these sometimes difficult situations, attesting to his understanding of the individual situations and his skills. Melvin S. Henderson, MD is shown. Photograph is reproduced with permission and ©American Academy of Orthopaedic Surgeons. Fifty Years of Progress, 1983.
Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty: an end-result study using a new method of result evaluation. J Bone Joint Surg Am. 1969;51:737–755.Henderson MS. Fractures of the femur: end results. J Bone Joint Surg Am. 1921;3:520–528.Larson CB. Rating scale for hip disabilities. Clin Orthop Relat Res. 1963;31:85–93.Mostofi SB. Who's Who in Orthopedics. London, UK: Springer; 2005.Wickstrom JK. Fifty years of the American Board of Orthopaedic Surgery: 1934. Clin Orthop Relat Res. 1990;257:3–10.
PMCID: PMC2505283  PMID: 18196372
21.  Radiation risk from fluoroscopically-assisted anterior cruciate ligament reconstruction 
Precise tunnel positioning is crucial for success in anterior cruciate ligament (ACL) reconstruction. The use of intra-operative fluoroscopy has been shown to improve the accuracy of tunnel placement. Although radiation exposure is a concern, we lack information on the radiation risk to patients undergoing fluoroscopically-assisted ACL reconstruction with a standard C-arm. The aim of our study was to determine the mean radiation doses received by our patients.
Radiation doses were recorded for 18 months between 1 April 2007 and 30 September 2008 for 58 consecutive patients undergoing ACL reconstruction assisted by intra-operative fluoroscopy. Dose area product (DAP) values were used to calculate the entrance skin dose (ESD), an indicator of potential skin damage and the effective dose (ED), an indicator of long-term cancer risk, for each patient.
The median age of 58 patients included in data analysis was 28 years (range, 14–52 years), of whom 44 were male (76%). The mean ESD during intra-operative fluoroscopy was 0.0015 ± 0.0029 Gy. The mean ED was 0.001 ± 0.002 mSv. No results exceeded the threshold of 2 Gy for skin damage, and the life-time risk of developing new cancer due to intra-operative fluoroscopy is less than 0.0001%.
Radiation doses administered during fluoroscopically-assisted ACL reconstruction were safe and do not represent a contra-indication to the procedure.
PMCID: PMC3025191  PMID: 20501019
Anterior cruciate ligament; Reconstruction; Intra-operative fluoroscopy; Radiation dose; Radiation risk
22.  Improved lag screw positioning in the treatment of proximal femur fractures using a novel computer assisted surgery method: a cadaveric study 
The importance of the tip-apex distance (TAD) to predict the cut-out risk of fixed angle hip implants has been widely discussed in the scientific literature. Intra-operative determination of TAD is difficult and can be hampered by image quality, body habitus, and image projection. The purpose of this paper is to evaluate, through a cadaveric study, a novel computer assisted surgery system (ADAPT), which is intended for intraoperative optimisation of lag screw positioning during antegrade femoral nailing. A 3D measure for optimal lag screw position, the tip-to-head-surface distance (TSD), is introduced.
45 intra-medullary hip screw procedures were performed by experienced and less experienced surgeons in a cadaveric test series: in 23 surgeries the ADAPT system was used, and in 22 it was not used. The position of the lag screw within the femoral head and neck was evaluated using post-operative CT scans. TAD, TSD, fluoroscopy as well as procedure time and variability were assessed.
The use of the ADAPT system increased accuracy in TSD values (i.e. smaller variability around the target value) for both groups of surgeons (interquartile range (IQR) of experienced surgeons: 4.10 mm (Conventional) vs. 1.35 mm (ADAPT) (p = 0.004)/IQR of less experienced surgeons: 3.60 mm (Conventional) vs. 0.85 mm (ADAPT) (p = 0.002)). The accuracy gain in TAD values did not prove to be significant in the grouped analysis (p = 0.269 for experienced surgeons; p = 0.066 for less experienced surgeons); however, the overall analysis showed a significant increase in accuracy (IQR: 4.50 mm (Conventional) vs. 2.00 mm (ADAPT) (p = 0.042)). The fluoroscopy time was significantly decreased by the use of the ADAPT system with a median value of 29.00 seconds (Conventional) vs. 17.00 seconds (ADAPT) for the less experienced surgeons (p = 0.046). There was no statistically significant impact on the procedure time (p = 0.739).
The ADAPT system improved the position of the lag screw within the femoral head, regardless of the surgeon’s level of clinical experience, and at the same time decreased overall fluoroscopy usage. These positive effects are achieved without increasing procedure time.
PMCID: PMC4074145  PMID: 24885741
Computer assisted surgery; Lag screw placement; Proximal femur fractures; Hip fractures; Cut-out; Surgical technique
23.  Clinical outcome after undisplaced femoral neck fractures 
Acta Orthopaedica  2011;82(3):268-274.
Background and purpose
Little attention has been paid to undisplaced femoral neck fractures. By using data from the Norwegian Hip Fracture Register, we investigated the risk of reoperation and the clinical outcome after treatment of these fractures in patients over 60 years of age.
Data on 4,468 patients with undisplaced femoral neck fractures who were operated with screw osteosynthesis were compared to those from 10,289 patients with displaced femoral neck fractures treated with screw osteosynthesis (n = 3,389) or bipolar hemiarthroplasty (n = 6,900). The evaluation was based on number of reoperations and patient assessment at 4 and 12 months of follow-up.
The 1-year implant survival was 89% after screw fixation for undisplaced fractures, 79% after screw fixation for displaced fractures, and 97% after hemiarthroplasty for displaced fractures. Patients with displaced fractures who were operated with internal fixation had a higher risk of reoperation (RR = 1.9, CI: 1.7–2.2), reported more pain, were less satisfied, and had lower quality of life than patients with undisplaced fractures treated with internal fixation (p < 0.05). Patients with displaced fractures who were operated with hemiarthroplasty had a lower risk of reoperation than patients with undisplaced fractures who were operated with internal fixation (RR = 0.32, CI: 0.27–0.38). Furthermore, they had the lowest degree of pain, were most satisfied, and reported the highest quality of life.
Interpretation The differences in clinical outcome found were less than what is considered to be of clinical importance. The results support the use of screw osteosynthesis for undisplaced femoral neck fractures in elderly patients, although even better results were obtained in the hemiarthroplasty group in patients with displaced fractures.
PMCID: PMC3235303  PMID: 21619501
Objective: we prospectively evaluated clinical and radiographic outcomes in patients with displaced combined transverse-posterior wall acetabular fractures managed at our Institution over a period of seven years by posterolateral single approach, direct posterior wall and posterior column reduction and plating, and indirect reduction of anterior column controlled by fluoroscopic images with or without lag-screw fixation. The aim was to identify if the obtained immediate postoperative Matta radiographic roof-arc angles after fracture reduction and fixation alters in the postoperative period when comparing posterior plating alone versus posterior plate and anterior column lag-screw fixation. Patients and Methods: 35 skeletally mature patients (31 male and four female, with mean age of 39.9 years old [range, 23.3 to 66.7 y/o]) with combined transverse-posterior wall acetabular fractures surgically treated by a posterolateral single approach were enrolled in this prospective investigation. Nineteen patients had associated orthopaedic injuries. The first part of the acetabular fracture management was similar to all patients and consisted in anatomical reduction and fixation of the transverse posterior component followed by anatomical reduction and fixation of the posterior wall component. The transverse anterior component reduction was controlled by fluoroscopic images (anteroposterior (AP), iliac oblique, and obturator oblique views) and digital palpation through the greater sciatic notch. Fifteen of the 35 patients had an additional lag-screw fixation from the posterior to the anterior columns with an extra-long small-fragment cortical screw. AP and Judet oblique radiographic views were taken at the end of the procedure and roof-arc angles were measured. Clinical results were assigned according to the grading system of Merle D'Aubigne´ and Postel as modified by Matta et al. Radiographic roof-arc angles were checked and compared between the two groups of patients to the same data collected both at the time of the surgical procedure and at three months postoperatively. Statistical analysis was done by either using chi-square (clinical outcome) and Mann-Whitney (roentgenographic outcome) tests, with a level of significance of α = 5%. Results: at final follow-up examination 18 to 84 months postoperatively (mean, 46.8 months), the clinical results were considered satisfactory in 31 (88.6%) patients (excellent in nine (25.7%) and good in 22 (62.9%) patients). There was no difference between patients with (n = 15) and without (n = 20) fixation of the transverse anterior component of the acetabular fracture (p = 0.67). Radiographic roof-arc angles measured at discharge, at three months postoperatively and at the last follow-up consultation didn't changed significantly (p > 0.05). There was no statistically significant difference between patients treated with (n = 15) and without (n = 20) fixation of the anterior component of the transverse acetabular fracture in terms of medial displacement of the femoral head. Conclusion: the authors suggest that associated transverse-posterior wall acetabular fractures can be managed by a single posterior approach. Direct reduction and fixation of the posterior wall and column components is an adequate option for these injuries. If there is adequate indirect reduction of the anterior column, as checked by digital palpation and fluoroscopy, we feel that it is not necessary to fix the anterior column component of the transverse acetabular fracture.
PMCID: PMC2719284  PMID: 19652723
acetabulum; fracture; transverse; posterior wall; roof-arc angle.
25.  2D-fluoroscopic based navigation for Gamma 3 nail insertion versus conventional procedure- a feasibility study 
Intramedullary nailing is a standard surgical procedure for fixation of proximal femoral fractures, but is associated with considerable radiation exposure for controlling the implant placement, due to the percutaneous insertion technique.
The aim of this study was the evaluation of potential benefits of 2D-fluoroscopic based navigation focused on the reduction of radiation exposure, a decrease of procedure time, as well as an increase of accuracy for Gamma3 nail insertions.
Twenty randomized Gamma3 nail insertions were performed in non-fractured synthetic femora according to the manufactures operation guidelines (group I) or with use of a 2D-fluoroscopic based navigation system (group II). Time of different steps of the procedure and the radiation exposure were measured, as well as the accuracy evaluated in postoperative CT scans.
Results and discussion
All Gamma3 nails were placed without any technical problems. Independent of the used procedure, the overall operating time (group I: 584 ± 99.2 sec; group II: 662 ± 64.9 sec; p=0.06) and accuracy of the final nail-positions were equivalent, but the radiation exposure was significantly reduced (92% reduction in fluoroscopic images and 91% reduction in fluoroscopic time, p< 0.01), using the 2D fluoroscopic based navigation procedure.
2D-fluoroscopic based navigation for Gamma3 nail insertion facilitates a relevant reduction of radiation exposure with equivalent accuracy of the final implant position and no prolonged operating time. This promising procedure modification is independent of different cephalomedullary implant manufacturers and specific implant designs, but needs to be evaluated in further clinical settings.
PMCID: PMC3599133  PMID: 23448230
Femoral fracture; Navigation; Gamma nail; Geriatric traumatology; Computer assisted surgery; Fluoroscopic navigation; Proximal femoral nailing; Cephalomedullary nail; Trochanteric fracture; Radiation exposure

Results 1-25 (1462216)