Search results for: femoral

Authors: Renate Krassnig, Gloria M. Hohenberger, Uldis Berzins, Stefen Fischerauer

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Background: Only a few reports discuss the effectiveness of intraoperative radiographs for placing femoral components. Therefore there is no international standard in using intraoperative imaging in the proceeding of total hip replacement. Method: Case report; an 84-year-old female patient underwent changing the components of the Total hip arthroplasty (THA) because of aseptic loosening. Due to circumstances, the surgeon decided to implant a cemented femoral component. The procedure was without any significant abnormalities. The first postoperative radiograph was planned after recovery – as usual. The x-ray imaging showed a misplaced femoral component. Therefore a CT-scan was performed additionally and the malposition of the cemented femoral component was confirmed. The patient had to undergo another surgery – removing of the cemented femoral component and implantation of a new well placed one. Conclusion: Intraoperative imaging of the femoral component is not a common standard but this case shows that intraoperative imaging is a useful method for detecting errors and gives the surgeon the opportunity to correct errors intraoperatively.

Keywords: femoral component, intraoperative imaging, malplacement, revison

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Authors: P. Panwalkar, K. Veravalli, M. Tofighi, A. Mofidi

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Introduction: Anterior femoral perforation or distal anterior nail position is a known complication of femoral nailing specifically in pertrochantric fractures fixed with cephalomedullary nail. This has been attributed to wrong entry point for the femoral nail, nail with large radius of curvature or malreduced fracture. Left alone anterior perforation of femur or abutment of nail on anterior femur will result in pain and risk stress riser at distal femur and periprosthetic fracture. There have been multiple techniques described to avert or correct this problem ranging from using different nail, entry point change, poller screw to deflect the nail position, use of shorter nail or use of curved guidewire or change of nail to ensure a nail with large radius of curvature Methods: We present this technique which we have used in order to centralise the femoral nail either when the nail has been put anteriorly or when the guide wire has been inserted too anteriorly prior to the insertion of the nail. This technique requires the use of femoral reduction spool from the nailing set. This technique was used by eight trainees of different level of experience under supervision. Results: This technique was easily reproducible without any learning curve without a need for opening of fracture site or change in the entry point with three different femoral nailing sets in twenty-five cases. The process took less than 10 minutes even when revising a malpositioned femoral nail. Conclusion: Our technique of using femoral reduction spool is easily reproducible and repeatable technique for avoidance of non-centralised femoral nail insertion and distal anterior perforation of femoral nail.

Keywords: femoral fracture, nailing, malposition, surgery

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Authors: Sang Hun Park, Chul Gyu Song

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Artery and vein occlusion changes observed in patients and experimental animals are unexplainable symptoms. As the fat accumulated in cardiovascular ruptures, it causes vascular blocking. Likewise, early detection of cardiovascular disease can be useful for treatment. In this study, we used the mouse femoral occlusion model to observe the arterial and venous occlusion changes without darkroom. We observed the femoral arterial flow pattern changes by proposed fluorescent imaging system using an animal model of thrombosis. We adjusted the near-infrared light source current in order to control the intensity of the fluorescent substance light. We got the clear fluorescent images and femoral artery flow pattern were measured by a 5-minute interval. The result showed that the fluorescent substance flowing in the femoral arteries were accumulated in thrombus as time passed, and the fluorescence of other vessels gradually decreased.

Keywords: thrombus, fluorescence, femoral, arteries

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Authors: Rami Jahmani

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Closed femoral-shortening osteotomy over an intramedullary nail for the treatment of leg length discrepancy (LLD) is a demanding surgical technique, classically requiring specialized instrumentation (intramedullary saw and chisel). The paper describes a modified surgical technique of performing femoral shortening percutaneously, using a percutaneous multiple drill-hole osteotomy technique to smash the bone, and then, the bone is fixed using intramedullary locked nail. Paper presents the result of performing nine cases of shortening as well.

Keywords: —Femoral shortening, Leg length discrepancy, Minimal invasive, Percutaneous osteotomy.

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Authors: S. Alireza Mirghasemi, Shervin Rashidinia, Mohammad Saleh Sadeghi, Mohsen Talebizadeh, Narges Rahimi Gabaran, Seyed Shahin Eftekhari, Sara Shahmoradi

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Avascular necrosis of femoral head is a pathologic condition that the main cause is decreased blood supply of femoral head. Among predisposing risk factors, chronic use of corticosteroids, alcoholism, smocking and hip traumas have more important role. Also we can mention OCP consumption as a risk factor among less common predisposing factors that lead to AVNF, in this study we introduce another cause of AVNF with a period of treatment with moderate dose of corticosteroids accompanied by OCP as a probable facilitating factor that leads to AVNF.

Keywords: AVN, corticosteroids consumption, femoral head osteonecrosis, OCP

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Authors: Jai Hyung Park, Eugene Kim, Jin Hun Park, Min Joon Oh

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Introduction: Subchondral insufficiency fracture of the femoral head (SIF) is a rare complication; however, it has been recognized to cause femoral head collapse. Subchondral insufficiency fracture (SIF) is caused by normal or physiological stress without any trauma. It has been reported in osteoporotic patients after the fixation of the proximal femur with an Intramedullary nail. Case presentation: We reported 5 cases with SIF of the femoral head after proximal femur fracture fixation with Intra-medullary nail. All patients had osteoporosis as an underlying disease. Good reduction was achieved in all 5 patients. SIF was found from about 3 months to 4 years after the initial operation, and all the fractures were solidly united at the final diagnosis. We investigated retrospectively the feature of those cases and several factors that affected the occurrence of SIF. Discussion: There are a few discussions regarding the SIF of the femoral head. These discussions may include the predisposing risk factors, how to diagnose the SIF in osteoporotic patients, and the peri-operative factors to prevent SIF. Conclusion: Subchondral insufficiency fracture of the femoral head is a considerable complication after the internal fixation of the proximal femur. There are several factors that can be modified. If they could be controlled in the peri-operative period, SIF could be prevented or handled in advance. Other options related to arthroplasty can be considered in old osteoporotic patients.

Keywords: insufficiency fracture of femoral head, intra-medullary nail, osteoporosis, proximal femur fracture

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Authors: Rajendra Kanojia

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Femoral components with inbuilt rotation require thicker flexion resection of the lateral femoral condyle and could potential risk to damage the popliteus tendon especially in the smaller Asian knees. We prospectively evaluated 10 patients with bilateral varus osteoarthritis knee to size the cuts and their location in relation to the popliteus tendon. Two different types of implant were used on either side, one side requires resection in 3° external rotation (group A) and other side femoral component with inbuilt external roation (group B). We had popliteus tendon injury in 3 knees all from group B. Risk of damaging the popliteus tendon was found higher in group B.

Keywords: popliteaus tendon injury, TKA, orthopaedic surgery, biomechanics and clinical applications

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Authors: M. Y. Lee, S. H. Park, S. M. Yu, H. S. Jo, C. G. Song

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Photoacoustic imaging is the imaging technology that combines the optical imaging with ultrasound. It also provides the high contrast and resolution due to optical and ultrasound imaging, respectively. For these reasons, many studies take experiment in order to apply this method for many diagnoses. We developed the real-time photoacoustic tomography (PAT) system using linear-ultrasound transducer. In this study, we conduct the experiment using swine and detect the blood of carotid artery and femoral artery. We measured the blood of femoral and carotid artery of swine and reconstructed the image using 950nm due to the HbO₂ absorption coefficient. The photoacoustic image is overlaid with ultrasound image in order to match the position. In blood of artery, major composition of blood is HbO₂. In this result, we can measure the blood of artery.

Keywords: photoacoustic tomography, swine artery, carotid artery, femoral artery

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Authors: Andrew Tan Hwee Chye, Yeo Zhen Ning

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This study aims to meta-analyse clinical studies comparing femoral tunnel position (FTP), femoral tunnel length (FTL) and graft bending angle (GBA) of single-bundle Anterior Cruciate Ligament (ACL) reconstruction using Transtibial (TT), Anteromedial (AM) and Outside-in (OI) techniques. A meta-analysis comparing the FTP, FTL and GBA of single-bundle ACL reconstruction utilising the TT, AM and OI was performed. Prospective Comparative Studies (PCS) and Retrospective Comparative Studies (RCS) from PubMed, Cochrane Library, and Embase were included. A total of 17 studies were included in this study. TT had the longest FTL, when compared to AM (Mean difference = 7.38, 95% CI: 3.76 to 11.00, P < 0.001) and OI (Mean difference = 9.47, 95% CI: 4.89 to 14.05, P < 0.001). In the deep-to-shallow direction, the OI resulted in a significantly deeper femoral tunnel as compared to the TT (Mean difference = 4.36, 95% CI: 1.39 to 7.33, P = 0.004) (Figure 6B). The AM technique also contributed to a significantly lower tunnel position as compared to the OI technique (Mean difference = 2.34, 95% CI: 0.76 to 3.92, P = 0.004). There were no significant differences in the graft bending angle between TT, AM and OI techniques. AM and OI techniques provide a more anatomical position as compared to the TT. Although FTL in the TT is longer than the AM and OI, all three techniques exceed the critical length of 25mm. There are no differences in the GBA between the three techniques.

Keywords: femoral tunnel position, femoral tunnel length, anterior cruciate ligament, transtibial, graft bending angle, anteromedial, outside-in

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Authors: Hansraj Riteesh Bookun, Emily Maree Stevens, Jarryd Leigh Solomon, Anthony Chan

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Objective: This was a retrospective cross-sectional study evaluating the safety and efficacy of femoral endarterectomy using the eversion technique with transection as opposed to the conventional endarterectomy technique with either vein or synthetic patch arterioplasty. Methods: Between 2010 to mid 2017, 19 patients with mean age of 75.4 years, underwent eversion femoral endarterectomy with transection by a single surgeon. There were 13 males (68.4%), and the comorbid burden was as follows: ischaemic heart disease (53.3%), diabetes (43.8%), stage 4 kidney impairment (13.3%) and current or ex-smoking (73.3%). The indications were claudication (45.5%), rest pain (18.2%) and tissue loss (36.3%). Results: The technical success rate was 100%. One patient required a blood transfusion following bleeding from intraoperative losses. Two patients required blood transfusions from low post operative haemogloblin concentrations – one of them in the context of myelodysplastic syndrome. There were no unexpected returns to theatre. The mean length of stay was 11.5 days with two patients having inpatient stays of 36 and 50 days respectively due to the need for rehabilitation. There was one death unrelated to the operation. Conclusion: The eversion technique with transection is safe and effective with low complication rates and a normally expected length of stay. It poses the advantage of not requiring a synthetic patch. This technique features minimal extraneous dissection as there is no need to harvest vein for a patch. Additionally, future endovascular interventions can be performed by puncturing the native vessel. There is no change to the femoral bifurcation anatomy after this technique. We posit that this is a useful adjunct to the surgeon’s panoply of vascular surgical techniques.

Keywords: endarterectomy, eversion, femoral, vascular

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Authors: K. Chalernpon, P. Aroonjarattham, K. Aroonjarattham

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Total hip replacement had been one of the most successful operations in hip arthritis surgery. The purpose of this research had been to develop a dynamic hip contact of Thai femoral bone to analyze the stress distribution on the implant and the strain distribution on the bone model under daily activities and compared with the static load simulation. The results showed the different of maximum von Mises stress 0.14 percent under walking and 0.03 percent under climbing stair condition and the different of equivalent total strain 0.52 percent under walking and 0.05 percent under climbing stair condition. The muscular forces should be evaluated with dynamic condition to reduce the maximum von Mises stress and equivalent total strain.

Keywords: dynamic loading, static load, hip prosthesis, Thai femur, femoral bone, finite element analysis

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Authors: Vrinda Hari Ankolekar, Anne D. Souza, Mamatha Hosapatna

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Introduction: Precise anatomical assessment of femoral neck anteversion (FNA) and the neck shaft angles (NSA) would be essential in diagnosing the pathological conditions involving hip joint and its ligaments. FNA of greater than 20 degrees is considered excessive femoral anteversion, whereas a torsion angle of fewer than 10 degrees is considered femoral retroversion. Excessive femoral torsion is not uncommon and has been associated with certain neurologic and orthopedic conditions. The enlargement and maturation of the hip joint increases at the 20th week of gestation and the NSA ranges from 135- 140◦ at birth. Material and methods: 48 femurs were tagged according to the GA and two photographs for each femur were taken using Nikon digital camera. Each femur was kept on a horizontal hard desk and end on an image of the upper end was taken for the estimation of FNA and a photograph in a perpendicular plane was taken to calculate the NSA. The images were transferred to the computer and were stored in TIFF format. Microsoft Paint software was used to mark the points and Image J software was used to calculate the angles digitally. 1. Calculation of FNA: The midpoint of the femoral head and the neck were marked and a line was drawn joining these two points. The angle made by this line with the horizontal plane was measured as FNA. 2. Calculation of NSA: The midpoint of the femoral head and the neck were marked and a line was drawn joining these two points. A vertical line was drawn passing through the tip of the greater trochanter to the inter-condylar notch. The angle formed by these lines was calculated as NSA. Results: The paired t-test for the inter-observer variability showed no significant difference between the values of two observers. (FNA: t=-1.06 and p=0.31; NSA: t=-0.09 and p=0.9). The FNA ranged from 17.08º to 33.97 º on right and 17.32 º to 45.08 º on left. The NSA ranged from 139.33 º to 124.91 º on right and 143.98 º to 123.8 º on left. Unpaired t-test was applied to compare the mean angles between the second and third trimesters which did not show any statistical significance. This shows that the FNA and NSA of femur did not vary significantly during the third trimester. The FNA and NSA were correlated with the GA using Pearson’s correlation. FNA appeared to increase with the GA (r=0.5) but the increase was not statistically significant. A decrease in the NSA was also noted with the GA (r=-0.3) which was also statistically not significant. Conclusion: The present study evaluates the FNA and NSA of the femur in fetuses and correlates their development with the GA during second and third trimesters. The FNA and NSA did not vary significantly during the third trimester.

Keywords: anteversion, coxa antetorsa, femoral torsion, femur neck shaft angle

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Authors: Asmaa Hamdy, Israa Nassar, Tarek Aly

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Introduction: Femoral fractures are the most common presentation in the Emergency Department (ED), and they can present as isolated injuries or as part of a polytrauma situation. To provide optimum pain management care to these patients, practitioners must be well prepared and current with utilizing modern evidence-based knowledge and practices. Management of pain associated with fracture femur in the emergency department has a critical role in the satisfaction of patients and preventing further complications. This study aimed to evaluate the analgesic efficacy of ultrasound-guided femoral nerve block compared with intravenous fentanyl in fractures of the femur in patients presented to the Emergency Department. Patients and Methods: Fifty patients with femur fractures were divided into two groups: Group A: In this group (twenty-five patients) were given intravenous fentanyl 2 micro-grams/kg and re-assessed for pain by Visual Analogue Score (VAS). Group B: In this group (twenty-five patients) underwent ultrasonography-guided femoral nerve block and were re-assessed for pain by VAS. Results: VAS score on the movement of the fractured limb between group A and group B at a 10-minute post-intervention period shows P= 0.043, and hence the difference is significant. VAS score on the movement of the fractured limb between group A and group B during a 10-minute post-intervention period showed a significant difference. Seventeen patients in group A had major PID with a percentage of 63% VS 10 patients in group B with a percentage of 37%. conclusion: both femoral nerve block and intravenous fentanyl are effective in relieving pain in patients with femur fractures. But femoral nerve block provides better and more intense analgesia and major pain intensity difference in less time. Moreover, the use of FNB had fewer side effects and more Hemodynamics stability compared to opioids.

Keywords: femur fracture, nerve block, fentanyl, ultrasound guided

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Authors: Ronak Mishra, Sachin Kale

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Background: The clinical outcome of a new fixation device (femoral neck system, FNS) for femoral neck fractures is not described properly. The main purpose of this study was to evaluate the functional outcome of the patients of femoral neck fractures treated with FNS. Methods: A retrospective study was done among patients aged 60 years or less. On the basis of inclusion and exclusion criteria a final sample size of 30 was considered. Blood loss, type of fracture internal fixation, and length of clinical follow-up were all acquired from patient records. The volume of blood loss was calculated. The mean and standard deviation of continuous variables were reported (with range). Harris Hip score (HHS) And Post op xrays at intervals(6 weeks, 6 months ,12 months ) we used to clinically asses the patient. Results: Out of all 60% were females and 40% were males. The mean age of the patients was. 44.12(+-) years The comparison of functional outcomes of the patients treated with FNS using Harris Hip Score. It showed a highly significant comparison between the patients at post operatively , 6 weeks and 3 months and 12 months . There were no postoperative complications seen among the patients. Conclusion: FNS offers superior biomechanical qualities and greatly improved overall build stability. It allows for a significant reduction in operation time, potentially lowering risks and consequences associated with surgery.

Keywords: FNS, trauma, hip, neck femur fracture, minimally invasive surgery

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Authors: M. Haruna, O. O. Onafowokan, G. Holt, K. Anderson, R. G. Middleton

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Background: Requirements for satisfactory outcomes following total hip arthroplasty (THA) include restoration of femoral offset, version, and leg length. Various techniques have been described for restoring these biomechanical parameters, with leg length restoration being the most predominantly described. We describe a “quartered head technique” (QHT) which uses a stepwise series of femoral head osteotomies to identify and preserve the centre of rotation of the femoral head during THA in order to ensure reconstruction of leg length, offset and stem version, such that hip biomechanics are restored as near to normal as possible. This study aims to identify whether using the QHT during hip arthroplasty effectively restores leg length and femoral offset to within acceptable parameters. Methods: A retrospective review of 206 hips was carried out, leaving 124 hips in the final analysis. Power analysis indicated a minimum of 37 patients required. All operations were performed using an anterolateral approach by a single surgeon. All femoral implants were cemented, collarless, polished double taper CPT® stems (Zimmer, Swindon, UK). Both cemented, and uncemented acetabular components were used (Zimmer, Swindon, UK). Leg length, version, and offset were assessed intra-operatively and reproduced using the QHT. Post-operative leg length and femoral offset were determined and compared with the contralateral native hip, and the difference was then calculated. For the determination of leg length discrepancy (LLD), we used the method described by Williamson & Reckling, which has been shown to be reproducible with a measurement error of ±1mm. As a reference, the inferior margin of the acetabular teardrop and the most prominent point of the lesser trochanter were used. A discrepancy of less than 6mm LLD was chosen as acceptable. All peri-operative radiographs were assessed by two independent observers. Results: The mean absolute post-operative difference in leg length from the contralateral leg was +3.58mm. 84% of patients (104/124) had LLD within ±6mm of the contralateral limb. The mean absolute post-operative difference in offset from contralateral leg was +3.88mm (range -15 to +9mm, median 3mm). 90% of patients (112/124) were within ±6mm offset of the contralateral limb. There was no statistical difference noted between observer measurements. Conclusion: The QHT provides a simple, inexpensive yet effective method of maintaining femoral leg length and offset during total hip arthroplasty. Combining this technique with pre-operative templating or other techniques described may enable surgeons to reduce even further the discrepancies between pre-operative state and post-operative outcome.

Keywords: leg length discrepancy, technical tip, total hip arthroplasty, operative technique

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Authors: Vladyslav Povoroznyuk, Anna Musiienko, Nataliia Dzerovych, Roksolana Povoroznyuk

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Osteoporosis and obesity are widespread diseases in people over 50 years associated with changes in structure and body composition. Нigher body mass index (BMI) values are associated with greater bone mineral density (BMD). However, trabecular bone score (TBS) indirectly explores bone quality, independently of BMD. The aim of our study was to evaluate the relationship between the BMD and TBS parameters in Ukrainian men suffering from obesity. We examined 396 men aged 40-89 years. Depending on their BMI all the subjects were divided into two groups: Group I – patients with obesity whose BMI was ≥ 30 kg/m² (n=129) and Group II – patients without obesity and BMI of < 30 kg/m² (n=267). The BMD of total body, lumbar spine L₁-L₄, femoral neck and forearm were measured by DXA (Prodigy, GEHC Lunar, Madison, WI, USA). The TBS of L₁- L₄ was assessed by means of TBS iNsight® software installed on DXA machine (product of Med-Imaps, Pessac, France). In general, obese men had a significantly higher BMD of lumbar spine L₁-L₄, femoral neck, total body and ultradistal forearm (p < 0.001) in comparison with men without obesity. The TBS of L₁-L₄ was significantly lower in obese men compared to non-obese ones (p < 0.001). BMD of lumbar spine L₁-L₄, femoral neck and total body significantly differ in men aged 40-49, 50-59, 60-69, and 80-89 years (p < 0.05). At the same time, in men aged 70-79 years, BMD of lumbar spine L₁-L₄ (p=0.46), femoral neck (p=0.18), total body (p=0.21), ultra-distal forearm (p=0.13), and TBS (p=0.07) did not significantly differ. A significant positive correlation between the fat mass and the BMD at different sites was observed. However, the correlation between the fat mass and TBS of L₁-L₄ was also significant, though negative.

Keywords: bone mineral density, trabecular bone score, obesity, men

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Authors: Mohammad Al- Rawi, Ahmad Al- Jumaily

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This paper investigates the effect of developing arterial blockage at the abdominal aorta on the blood pressure waveform at an externally accessible location suitable for invasive measurements such as the brachial and the femoral arteries. Arterial blockages are created surgically within the abdominal aorta of healthy Wistar rats to create narrowing resemblance conditions. Blood pressure waveforms are measured using a catheter inserted into the right femoral artery. Measurements are taken at the baseline healthy condition as well as at four different severities (20%, 50%, 80% and 100%) of arterial blockage. In vivo and in vitro measurements of the lumen diameter and wall thickness are taken using Magnetic Resonance Imaging (MRI) and microscopic techniques, respectively. These data are used to validate a 3D computational fluid dynamics model (CFD) which is developed to generalize the outcomes of this work and to determine the arterial stress and strain under the blockage conditions. This work indicates that an arterial blockage in excess of 20% of the lumen diameter significantly influences the pulse wave and reduces the systolic blood pressure at the right femoral artery. High wall shear stress and low circumferential strain are also generated at the blockage site.

Keywords: arterial blockage, pulse wave, atherosclerosis, CFD

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Authors: Mamatha Hosapatna, Anne D. Souza, Vrinda Hari Ankolekar, Antony Sylvan D. Souza

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Introduction: The lower extremity of the femur is characterized by an anterior groove in which patella is held during motion. This groove separates the two lips of the trochlea (medial and lateral), prolongation of the two condyles. In humans, the lateral trochlear lip is more developed than the medial one, creating an asymmetric groove that is also specific to the human body. Because of femoral obliquity, contraction of quadriceps leads to a lateral dislocation stress on the patella, and the more elevated lateral side of the patellar groove helps the patella stays in its correct place, acting as a wall against lateral dislocation. This specific shape fits an oblique femur. It is known that femoral obliquity is not genetically determined but comes with orthostatism and biped walking. Material and Methodology: To measure the various dimensions of the Femoropatellar groove (FPG) and femoral condyle using digital image analyser. 37 dried adult femora (22 right,15 left) were used for the study. End on images of the lower end of the femur was taken. Various dimensions of the Femoropatellar groove and FP angle were measured using image J software. Results were analyzed statistically. Results: Maximum of the altitude of medial condyle of the right femur is 4.98± 0.35 cm and of the left femur is 5.20±.16 cm. Maximum altitude of lateral condyle is 5.44±0.4 and 5.50±0.14 on the right and left side respectively. Medial length of the groove is 1.30±0.38 cm on the right side and on the left side is 1.88±0.16 cm. The lateral length of the groove on the right side is 1.900±.16 cm and left side is 1.88±0.16 cm. Femoropatellar angle is 136.38◦±2.59 on the right side and on the left side it is 142.38◦±7.0 Angle and dimensions of the femoropatellar groove on the medial and lateral sides were measured. Asymmetry in the patellar groove was observed. The lateral lip was found to be wider and bigger which correlated with the previous studies. An asymmetrical patellar groove with a protruding lateral side associated with an oblique femur is a specific mark of bipedal locomotion. Conclusion: Dimensions of FPG are important in maintaining the stability of patella and also in knee replacement surgeries. The implants used in to replace the patellofemoral compartment consist of a metal groove to fit on the femoral end and a plastic disc that attaches to the undersurface of the patella. The location and configuration of the patellofemoral groove of the distal femur are clinically significant in the mechanics and pathomechanics of the patellofemoral articulation.

Keywords: femoral patellar groove, femoro patellar angle, lateral condyle, medial condyle

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Authors: Keisuke Akiyama, Takashi Sakai, Junichiro Koyanagi, Hideki Yoshikawa, Kazuomi Sugamoto

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The geometry of acetabular cartilage surface plays an important role in hip joint biomechanics. The aim of this study was to analyze the morphology of acetabular articular cartilage surface in elderly subjects using a 3D-digitizer. Twenty hemipelves from 12 subjects (mean ages 85 years) were scanned with 3D-digitizer. Each acetabular surface model was divided into four regions: anterosuperior (AS), anteroinferior (AI), posterosuperior (PS), and posteroinferior (PI). In the global acetabulum and each region, the acetabular sphere radius and the standard deviation (SD) of the distance from the acetabular sphere center to the acetabular cartilage surface were calculated. In the global acetabulum, the distance between the acetabular surface model and the maximum sphere which did not penetrate over the acetabular surface model was calculated as the inferred femoral head, and then the distribution was mapped at intervals of 0.5 mm. The SD in AS was significantly larger than that in AI (p = 0.006) and PI (p = 0.001). The SD in PS was significantly larger than that in PI (p = 0.005). The closest region (0-0.5 mm) tended to be distributed at anterior or posterosuperior acetabular edge. The contact between the femoral head and acetabulum might start at the periphery of the lunate surface, especially in the anterior or posterosuperior region. From viewpoint of acetabular morphology, the acetabular articular cartilage in the anterior or posterosuperior edge could be more vulnerable due to direct contact mechanism.

Keywords: acetabulum, cartilage, morphology, 3D-digitizer

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Authors: Mohammad Alobaidy, David Nicoll, Tracey Wilkinson

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Background: Many patients suffer postoperative knee stability after total knee arthroplasty (joint replacement) involving posterior cruciate ligament (PCL) sacrificing or retaining, but is not clear whether the meniscofemoral ligaments (MFLs) are retained during these procedures; their function in terms of knee stability is not well established in the literature. Purpose: Macroscopic, detailed, morphometric investigation of the anterior and posterior MFLs of the knee joint was undertaken to assist understanding of knee stability after total knee arthroplasty and ligament reconstruction. Methods: Dissection of eighty Thiel embalmed knees from 19 male and 21 female cadavers was conducted, mean age 77 (range 47-99 years). The origin and insertion of the anterior and posterior MFLs were measured using high accuracy, calibrated, digital Vernier calipers at 0.01mm. Results: The means were: anterior meniscofemoral ligament (aMFL) length 28.4 ± 2.7mm; posterior meniscofemoral ligament (pMFL) length 29 ± 3.7mm; aMFL femoral width 6.4 ± 1.7mm, mid-distance ligament width 4 ± 1.1mm, meniscal ligament width 3.9 ± 1.2mm; pMFL femoral width 5.6 ± 1.5mm, mid-distance ligament width 4.1 ± 1.1mm, meniscal ligament width 4.1 ± 1.3mm. Some of the male measurements were larger than female, with significant differences in the length of the aMFL femoral length p<0.01 and pMFL femoral length p<0.007, and width of the pMFL mid-distance p<0.04. Conclusion: This study may help explore the role of the meniscofemoral ligaments in knee stability after total knee arthroplasty with a posterior cruciate ligament retaining prosthesis. Anatomical information for Thiel embalmed knees may aid orthopaedic surgeons in ligament reconstruction.

Keywords: anterior and posterior meniscofemoral ligaments, morphometric analysis, Thiel embalmed knees, knee arthroplasty

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Authors: Khaled Harrar, Rachid Jennane

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The purpose of this study is the discrimination of 28 postmenopausal with osteoporotic femoral fractures from an age-matched control group of 28 women using texture analysis based on fractals. Two pre-processing approaches are applied on radiographic images; these techniques are compared to highlight the choice of the pre-processing method. Furthermore, the values of the fractal dimension are compared to those of the fractal signature in terms of the classification of the two populations. In a second analysis, the BMD measure at proximal femur was compared to the fractal analysis, the latter, which is a non-invasive technique, allowed a better discrimination; the results confirm that the fractal analysis of texture on calcaneus radiographs is able to discriminate osteoporotic patients with femoral fracture from controls. This discrimination was efficient compared to that obtained by BMD alone. It was also present in comparing subgroups with overlapping values of BMD.

Keywords: osteoporosis, fractal dimension, fractal signature, bone mineral density

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Authors: Sanjeev K. Singh, Maloy B. Mandal, Revand R.

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The physiology of baroreceptors and chemoreceptors present in large blood vessels of the heart is well known in regulation of cardiorespiratory functions. Since large blood vessels and peripheral blood vessels are of same mesodermal origin, therefore, involvement of the latter in regulation of cardiorespiratory system is expected. Role of perivascular nerves in mediating cardiorespiratory alterations produced after intra-arterial injection of a nociceptive agent (bradykinin) was examined in urethane anesthetized male rats. Respiratory frequency, blood pressure, and heart rate were recorded for 30 min after the retrograde injection of bradykinin/saline in the femoral artery. In addition, paw edema was determined and water content was expressed as percentage of wet weight. Injection of bradykinin produced immediate tachypnoeic, hypotensive and bradycardiac responses of shorter latency (5-8 s) favoring the neural mechanisms involved in it. Injection of equi-volume of saline did not produce any responses and served as time matched control. Paw edema was observed in the ipsilateral hind limb. Pretreatment with diclofenac sodium significantly attenuated the bradykinin-induced responses and also blocked the paw edema. Ipsilateral femoral and sciatic nerve sectioning attenuated bradykinin-induced responses significantly indicating the origin of responses from the local vascular bed. Administration of bradykinin in the segment of an artery produced reflex cardiorespiratory changes by stimulating the perivascular nociceptors involving prostaglandins. This is a novel study exhibiting the role of peripheral blood vessels in regulation of cardiorespiratory system.

Keywords: vasosensory reflex, cardiorespiratory changes, nociceptive agent, bradykinin, VR1 receptors

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Authors: Ananya Ananya, Karthik Rao

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Accurate segmentation of knee cartilage in 3-D magnetic resonance (MR) images for quantitative assessment of volume is crucial for studying and diagnosing osteoarthritis (OA) of the knee, one of the major causes of disability in elderly people. Radiologists generally perform this task in slice-by-slice manner taking 15-20 minutes per 3D image, and lead to high inter and intra observer variability. Hence automatic methods for knee cartilage segmentation are desirable and are an active field of research. This paper presents design and experimental evaluation of 2D convolutional neural networks based fully automated methods for knee cartilage segmentation in 3D MRI. The architectures are validated based on 40 test images and 60 training images from SKI10 dataset. The proposed methods segment 2D slices one by one, which are then combined to give segmentation for whole 3D images. Proposed methods are modified versions of U-net and dilated convolutions, consisting of a single step that segments the given image to 5 labels: background, femoral cartilage, tibia cartilage, femoral bone and tibia bone; cartilages being the primary components of interest. U-net consists of a contracting path and an expanding path, to capture context and localization respectively. Dilated convolutions lead to an exponential expansion of receptive field with only a linear increase in a number of parameters. A combination of modified U-net and dilated convolutions has also been explored. These architectures segment one 3D image in 8 – 10 seconds giving average volumetric Dice Score Coefficients (DSC) of 0.950 - 0.962 for femoral cartilage and 0.951 - 0.966 for tibia cartilage, reference being the manual segmentation.

Keywords: convolutional neural networks, dilated convolutions, 3 dimensional, fully automated, knee cartilage, MRI, segmentation, U-net

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Authors: Deepthinath Reghunathan, Satheesha Nayak, Sudarshan S., Prasad Alathady Maloor, Prakash Shetty

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Lumbar plexus is formed by the union of ventral rami of T12, L1, L2, L3 spinal nerves and the larger upper division of L4 lumbar spinal nerves. Variations in the normal anatomy of the lumbar and sacral plexus might be seen in some cases and are reported in the literature, but finding such an unusual case comprising of multiple variations which is normally not expected in a clinical setup, proves to be a vital piece of information for clinicians and medical practitioners. During the dissection of the abdomen and pelvis of an approximately 70 year old cadaver, we observed the following variations in the formation of the lumbar and sacral nerves. 1. The genitofemoral nerve bifurcated at a higher level; genital branch of genitofemoral nerve gave branches to the anterior abdominal wall muscles, 2. A communicating branch was given from the lateral cutaneous nerve of thigh to the medial cutaneous nerve of thigh, 3. A muscular branch was given from femoral nerve to psoas major, 4. There was absence of contribution of L4 spinal nerve in the formation of the lumbosacral trunk and 5. Lumbosacral trunk gave communicating branches to the femoral and obturator nerves. Most of the variations found were rare and finding all the above said variations in a single cadaver is even rare. Documentation of such rare cases with multiple variations in the formation of nerves from the lumbar plexus provides vital information on such occurrences. This information would in turn improve the knowledge of clinicians and surgeons dealing with this region. Emphasizing such knowledge of this region would prevent accidental damage to the structures with a variant anatomy.

Keywords: femoral nerve, genitofemoral nerve, lumbar plexus, lumbosacral trunk

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Authors: Kwi Young Kang

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Objective: To determine the association between inflammatory and structural lesions on sacroiliac joint (SIJ) MRI and BMD and to identify risk factors for low BMD in patients with axial spondyloarthritis (axSpA). Methods: Seventy-six patients who fulfilled the ASAS axSpA criteria were enrolled. All underwent SIJ MRI and BMD measurement at the lumbar spine, femoral neck, and total hip. Inflammatory and structural lesions on SIJ MRI were scored. Laboratory tests and assessment of radiographic and disease activity were performed at the time of MRI. The association between SIJ MRI findings and BMD was evaluated. Results: Among the 76 patients, 14 (18%) had low BMD. Patients with low BMD showed significantly higher bone marrow edema (BME) and deep BME scores on MRI than those with normal BMD (p<0.047 and 0.007, respectively). Inflammatory lesions on SIJ MRI correlated with BMD at the femoral neck and total hip. Multivariate analysis identified the presence of deep BME on SIJ MRI, increased CRP, and sacroiliitis on X-ray as risk factors for low BMD (OR: 5.6, 14.6, and 2.5, respectively). Conclusion: The presence of deep BME on SIJ MRI, increased CRP levels, and severity of sacroiliitis on X-ray were independent risk factors for low BMD.

Keywords: axial spondyloarthritis, sacroiliac joint MRI, bone mineral density, sacroiliitis

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Authors: Wei Yao

Abstract:

A steerable and flexible drill is needed in orthopaedic surgery. For example, osteoarthritis is a common condition affecting millions of people for which joint replacement is an effective treatment which improves the quality and duration of life in elderly sufferers. Conventional surgery is not very accurate. Computer navigation and robotics can help increase the accuracy. For example, In Total Hip Arthroplasty (THA), robotic surgery is currently practiced mainly on acetabular side helping cup positioning and orientation. However, femoral stem positioning mostly uses hand-rasping method rather than robots for accurate positioning. The other case for using a flexible drill in surgery is Anterior Cruciate Ligament (ACL) Reconstruction. The majority of ACL Reconstruction failures are primarily caused by technical mistakes and surgical errors resulting from drilling the anatomical bone tunnels required to accommodate the ligament graft. The proposed new steerable drill system will perform orthopedic surgery through curved tunneling leading to better accuracy and patient outcomes. It may reduce intra-operative fractures, dislocations, early failure and leg length discrepancy by making possible a new level of precision. This technology is based on a robotically assisted, steerable, hand-held flexible drill, with a drill-tip tracking device and a multi-modality navigation system. The critical differentiator is that this robotically assisted surgical technology now allows the surgeon to prepare 'patient specific' and more anatomically correct 'curved' bone tunnels during orthopedic surgery rather than drilling straight holes as occurs currently with existing surgical tools. The flexible and steerable drill and its navigation system for femoral milling in total hip arthroplasty had been tested on sawbones to evaluate the accuracy of the positioning and orientation of femoral stem relative to the pre-operative plan. The data show the accuracy of the navigation system is better than traditional hand-rasping method.

Keywords: navigation, robotic orthopedic surgery, steerable drill, tracking

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Authors: S. Ayeko, J. Milton, C. Hughes, K. Anderson, R. G. Middleton

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Background: Periprosthetic femoral fractures (PFF) in association with hip hemiarthroplasty or total hip arthroplasty is a common and serious complication. In the Vancouver Classification system algorithm, B1 fractures should be treated with Open Reduction and Internal Fixation (ORIF) and preferentially revised in combination with ORIF if B2 or B3. This study aims to assess patient outcomes after plate osteosynthesis alone for Vancouver B1 and B2 fractures. The main outcome is the 1-year re-revision rate, and secondary outcomes are 30-day and 1-year mortality. Method: This is a retrospective single-centre case-series review from January 2016 to June 2021. Vancouver B1 and B2, non-malignancy fractures in adults over 18 years of age treated with polyaxial Non-Contact Bridging plate osteosynthesis, have been included. Outcomes were gathered from electronic notes and radiographs. Results: There were 50 B1 and 64 B2 fractures. 26 B2 fractures were managed with ORIF and revision, 39 ORIF alone. Of the revision group, one died within 30 days (3.8%), one at one year (3.8%), and two were revised within one year (7.7). Of the B2 ORIF group, three died within 30-day mortality (7.96%), eight at one year (21.1%), and 0 were revised in 1 year. Conclusion: This study has demonstrated that satisfactory outcomes can be achieved with ORIF, excluding revision in the management of B2 fractures.

Keywords: arthroplasty, bridging plate, periprosthetic fracture, revision surgery

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Authors: Charlotte K. Lee, Henrique R. N. Aguiar, Ralph Smith, James Baldock, Sam Botchey

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Background: Femoral neck stress fractures (FNSF) are uncommon, making up 1 to 7.2% of stress fractures in healthy subjects. FNSFs are prevalent in young women, military recruits, endurance athletes, and individuals with energy deficiency syndrome or female athlete triad. Presentation is often non-specific and is often misdiagnosed following the initial examination. There is limited research addressing the return–to–activity time after FNSF. Previous studies have demonstrated prognostic time predictions based on various imaging techniques. Here, (1) OxSport clinic FNSF practice standards are retrospectively reviewed, (2) FNSF cohort demographics are examined, (3) Regression models were used to predict return–to–activity prognosis and consequently determine bone stress risk factors. Methods: Patients with a diagnosis of FNSF attending Oxsport clinic between 01/06/2020 and 01/01/2020 were selected from the Rheumatology Assessment Database Innovation in Oxford (RhADiOn) and OxSport Stress Fracture Database (n = 14). (1) Clinical practice was audited against five criteria based on local and National Institute for Health Care Excellence guidance, with a 100% standard. (2) Demographics of the FNSF cohort were examined with Student’s T-Test. (3) Lastly, linear regression and Random Forest regression models were used on this patient cohort to predict return–to–activity time. Consequently, an analysis of feature importance was conducted after fitting each model. Results: OxSport clinical practice met standard (100%) in 3/5 criteria. The criteria not met were patient waiting times and documentation of all bone stress risk factors. Importantly, analysis of patient demographics showed that of the population with complete bone stress risk factor assessments, 53% were positive for modifiable bone stress risk factors. Lastly, linear regression analysis was utilized to identify demographic factors that predicted return–to–activity time [R2 = 79.172%; average error 0.226]. This analysis identified four key variables that predicted return-to-activity time: vitamin D level, total hip DEXA T value, femoral neck DEXA T value, and history of an eating disorder/disordered eating. Furthermore, random forest regression models were employed for this task [R2 = 97.805%; average error 0.024]. Analysis of the importance of each feature again identified a set of 4 variables, 3 of which matched with the linear regression analysis (vitamin D level, total hip DEXA T value, and femoral neck DEXA T value) and the fourth: age. Conclusion: OxSport clinical practice could be improved by more comprehensively evaluating bone stress risk factors. The importance of this evaluation is demonstrated by the population found positive for these risk factors. Using this cohort, potential bone stress risk factors that significantly impacted return-to-activity prognosis were predicted using regression models.

Keywords: eating disorder, bone stress risk factor, femoral neck stress fracture, vitamin D

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Authors: Soyeon Kang, Youn-Jee Chung, Jung Namkung

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Objective: This retrospective study investigated the association between uric acid level and bone mineral density (BMD) in the postmenopausal period. Methods: The study included 328 menopausal women (mean age, 57.3 ± 6.5 years; mean serum uric acid level, 4.6 ± 1.0 mg/dL). Patients were divided into three groups by tertile of serum uric acid level. Patients who used hormone treatment (HT), bisphosphonates, or lipid-lowering agents were included. Results: Blood urea nitrogen, serum creatinine, and serum triglyceride levels were significantly higher in the upper uric acid tertiles. No significant difference was found in the mean uric acid levels between medication users and non-users. Distinct HT regimens showed different mean serum uric acid levels. In a cross-sectional analysis, higher serum uric acid levels showed a tendency toward increased BMD in the spine and femoral neck. Longitudinal analysis of 186 women who underwent follow-up examination at a mean interval of 14.6 months revealed a trend toward a smaller reduction in femoral neck BMD in women in the upper serum uric acid tertiles. Conclusion: A positive correlation exists between serum uric acid levels and BMD in menopausal women.

Keywords: menopause, antioxidant, uric acid, bone mineral density

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Authors: Pedro Gomes, Luís Sá Castelo, António Lopes, Marta Maio, Pedro Mota, Adélia Avelar, António Marques Dias

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Introduction: Total Knee Arthroplasty (TKA) has contributed to improvement of patient`s quality of life, although it has been associated with some complications including component loosening and polyethylene wear. To prevent these complications various fixation techniques have been employed. Hybrid TKA with cemented tibial and cementless femoral components have shown favourable outcomes, although it still lack of consensus in the literature. Objectives: To evaluate the clinical and radiographic results of hybrid versus cemented TKA with an average 5 years follow-up and analyse the survival rates. Methods: A retrospective study of 125 TKAs performed in 92 patients at our institution, between 2006 to 2008, with a minimum follow-up of 2 years. The same prosthesis was used in all knees. Hybrid TKA fixation was performed in 96 knees, with a mean follow-up of 4,8±1,7 years (range, 2–8,3 years) and 29 TKAs received fully cemented fixation with a mean follow-up of 4,9±1,9 years (range, 2-8,3 years). Selection for hybrid fixation was nonrandomized and based on femoral component fit. The Oxford Knee Score (OKS 0-48) was evaluated for clinical assessment and Knee Society Roentgenographic Evaluation Scoring System was used for radiographic outcome. The survival rate was calculated using the Kaplan-Meier method, with failures defined as revision of either the tibial or femoral component for aseptic failures and all-causes (aseptic and infection). Analysis of survivorship data was performed using the log-rank test. SPSS (v22) was the computer program used for statistical analysis. Results: The hybrid group consisted of 72 females (75%) and 24 males (25%), with mean age 64±7 years (range, 50-78 years). The preoperative diagnosis was osteoarthritis (OA) in 94 knees (98%), rheumatoid arthritis (RA) in 1 knee (1%) and Posttraumatic arthritis (PTA) in 1 Knee (1%). The fully cemented group consisted of 23 females (79%) and 6 males (21%), with mean age 65±7 years (range, 47-78 years). The preoperative diagnosis was OA in 27 knees (93%), PTA in 2 knees (7%). The Oxford Knee Scores were similar between the 2 groups (hybrid 40,3±2,8 versus cemented 40,2±3). The percentage of radiolucencies seen on the femoral side was slightly higher in the cemented group 20,7% than the hybrid group 11,5% p0.223. In the cemented group there were significantly more Zone 4 radiolucencies compared to the hybrid group (13,8% versus 2,1% p0,026). Revisions for all causes were performed in 4 of the 96 hybrid TKAs (4,2%) and 1 of the 29 cemented TKAs (3,5%). The reason for revision was aseptic loosening in 3 hybrid TKAs and 1 of the cemented TKAs. Revision was performed for infection in 1 hybrid TKA. The hybrid group demonstrated a 7 years survival rate of 93% for all-cause failures and 94% for aseptic loosening. No significant difference in survivorship was seen between the groups for all-cause failures or aseptic failures. Conclusions: Hybrid TKA yields similar intermediate-term results and survival rates as fully cemented total knee arthroplasty and remains a viable option in knee joint replacement surgery.

Keywords: hybrid, survival rate, total knee arthroplasty, orthopaedic surgery

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