Comparative evaluation of radiographic morphologic parameters for predicting subsequent contralateral fragility hip fracture

Predicting mechanical complications in proximal femoral nailing for elderly patients: a radiological scoring system based on a single-centre retrospective cohort with 586 cases

BACKGROUND

Proximal femoral nailing (PFN) is a preferred treatment for intertrochanteric femoral fractures in elderly patients due to its minimally invasive nature and early mobilisation benefits. However, mechanical complications such as implant failure, cutout, and reduction collapse remain significant challenges. This study introduces the targeted surgical score (TSS), a novel scoring system designed to predict and mitigate mechanical complications by evaluating modifiable surgical factors.

METHODS

A retrospective analysis of 586 patients aged 65 and older treated with PFN between 2015 and 2022 was conducted. Data on demographic characteristics, fracture classifications, and surgical parameters were collected. Radiographic assessments included tip-apex distance (TAD) and lag screw positioning for implant placement quality, medial and anterior cortical support (MCS and ACS), and fracture alignment in both AP and lateral planes for reduction quality. Each parameter was scored, resulting in a cumulative TSS ranging from 0 to 8. Logistic regression and ROC curve analysis were performed to evaluate the predictive capacity of TSS.

RESULTS

The average TSS was 4.06 ± 2.22 in the complication group and 6.14 ± 1.56 in the non-complication group (p < 0.001). A one-point increase in TSS was associated with a 44.9% reduction in complication risk (OR 0.551; p < 0.001). Independent risk factors included lag screw placement (non-central superior quadrants), inadequate cortical support in AP and lateral planes (MCS and ACS), and TAD (≥ 25 mm). The TSS demonstrated relatively good discriminative ability with an AUC of 0.768.

CONCLUSION

TSS may aid in predicting and mitigating mechanical complications while potentially guiding surgical applications in PFN, but further prospective multicentre validation is required. While certain parameters of TSS could be considered intraoperatively, its full implementation may be more practical for postoperative risk assessment.

Utility of Radiographic Parameter in Assessing Bone Density and Subsequent Fractures in Patients With Osteoporotic Vertebral Compression Fracture

OBJECTIVE

To investigate the ability of radiological parameter canal bone ratio (CBR) to assess bone mineral density and to differentiate between patients with primary and multiple osteoporotic vertebral compression fracture (OVCF).

METHODS

A retrospective analysis was conducted on OVCF patients treated at our hospital. CBR was measured through full-spine x-rays. Patients were categorized into primary and multiple fracture groups. Receiver operating characteristic curve analysis and area under the curve (AUC) calculation were used to assess the ability of parameters to predict osteoporosis and multiple fractures. Predictors of T values were analyzed by multiple linear regression, and independent risk factors for multiple fractures were determined by multiple logistic regression analysis.

RESULTS

CBR showed a moderate negative correlation with dual-energy x-ray absorptiometry T values (r = -0.642, p < 0.01). Higher CBR (odds ratio [OR], -6.483; 95% confidence interval [CI], -8.234 to -4.732; p < 0.01) and lower body mass index (OR, 0.054; 95% CI, 0.023-0.086; p < 0.01) were independent risk factors for osteoporosis. Patients with multiple fractures had lower T values (mean ± standard deviation [SD]: -3.76 ± 0.73 vs. -2.83 ± 0.75, p < 0.01) and higher CBR (mean ± SD: 0.54 ± 0.07 vs. 0.46 ± 0.06, p < 0.01). CBR had an AUC of 0.819 in predicting multiple fractures with a threshold of 0.53. T values prediction had an AUC of 0.816 with a threshold of -3.45. CBR > 0.53 was an independent risk factor for multiple fractures (OR, 14.66; 95% CI, 4.97-43.22; p < 0.01).

CONCLUSION

CBR is negatively correlated with bone mineral density (BMD) and can be a novel opportunistic BMD assessment method. It is a simple and effective measurement index for predicting multiple fractures, with predictive performance not inferior to T values.

Cortical Thickness Index and Canal Calcar Ratio: A Comparison of Proximal Femoral Fractures and Non-Fractured Femora in Octogenarians to Centenarians

Background: The cortical thickness index (CTI) is a measure of bone quality and it correlates with the risk of proximal femoral fractures. The purpose of this study was to investigate the CTI in femoral neck, trochanteric fractures and non-fractured femora in geriatric patients and to determine whether there is a correlation between the CTI and the presence of a fracture. Methods: One hundred and fifty patients (fifty femoral neck- (FNFx), fifty trochanteric fractures (TFx) and fifty non-fractured (NFx)) with a mean age of 91 (range 80-104) years were included. Hip radiographs (antero-posterior (ap), lateral) were evaluated retrospectively. Measurements on the proximal femoral inner and outer cortices, including CTI and Dorr's canal calcar ratio (CCR), were assessed for inter-observer reliability (ICC), differences of each fracture and correlation of parameters. Results: The mean ap CTI on the affected side was 0.43, 0.45 and 0.55 for FNFx, TFx and NFx, respectively. There was a significant difference of the ap CTI and CCR comparing the injured and healthy side for both fracture cohorts (p < 0.001). Patients with FNFx or TFx had significantly lower CTI on both sides compared to the NFx group (p < 0.05). There was no difference for CTI (p = 0.527) or CCR (p = 0.291) when comparing both sides in the NFx group. The mean inter-observer reliability was good to excellent (ICC 0.88). Conclusions: In proximal femoral fractures, the CTI and CCR are reduced compared with those in non-fractured femora. Both parameters are reliable and show a good correlation in geriatric patients. Therefore, especially for geriatric patients, the CTI and CCR may help to predict fracture risk and consult patients in daily practice.

The importance of radiological parameters of proximal femoral morphology in recovery management of patients with avascular necrosis undergoing hip arthroplasty

Background and Objectives: Our study aimed to radiologically assess the morphology of the proximal femur in patients with avascular necrosis (AVN). We considered that the correct evaluation of the proximal femur morphology is essential and shows multiple clinical applications that can impact patient recovery and outcome. Materials and Methods: Our study included 177 patients (85 male and 92 female) with AVN regardless of the degree. The patients were assessed by bilateral hip X-ray in the supine position. We selected the most common radiographic parameters to evaluate for all patients: cortical thickness index (CTI), canal flare index (CFI), calcar-to-canal ratio (CCR), and morphological cortical index (MCI). Results: Average values for the parameters were: CTI = 0.5192 ± 0.07528, CFI= 3.5515 ± 0.5071, CCR = 0.4469 ± 0.05363 and MCI = 2.7572 ± 0.07704. We found no statistically significant differences between genders, except for CFI (p = 0.0325). Conclusions: The anatomical configuration of the proximal femur can play a major role in the process of planning the appropriate implant for total hip arthroplasty, as well as in the proper positioning of the implant during the surgical procedure. A thorough knowledge of the proximal femur morphology can be of great use to the orthopedic surgeon and may help decrease perioperative complications.