Reduced Risk of Reoperation Using Intramedullary Nailing with Femoral Neck Protection in Low-Energy Femoral Shaft Fractures

Bögl, Hans Peter; Zdolsek, Georg; Michaëlsson, Karl; Höijer, Jonas; Schilcher, Jörg

doi:10.2106/jbjs.20.00160

Cited by 14 publications

(8 citation statements)

References 40 publications

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“…We chose to exclude AFF cases from the gold-standard classification if their radiographs showed pre-existing implants in the ipsilateral femur. This was in line with our previous research ( 3 , 9 , 10 , 12 – 23 ) and according to interpretations ( 24 ) of the internationally accepted case definition of AFF proposed by ASBMR ( 2 ). However, recent studies have questioned the exclusion of peri-implant fractures as AFFs ( 24 ).…”

Section: Discussionsupporting

confidence: 92%

Surveillance of atypical femoral fractures in a nationwide fracture register

Bögl

Zdolsek

Barnisin

et al. 2022

ActaO

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Background and purpose — To continuously assess the incidence of atypical femoral fractures (AFFs) in the population is important, to allow the evaluation of the risks and benefits associated with osteoporosis treatment. Therefore, we investigated the possibility to use the Swedish Fracture Register (SFR) as a surveillance tool for AFFs in the population and to explore means of improvement. Patients and methods — All AFF registrations in the SFR from January 1, 2015 to December 31, 2018 were enrolled in the study. For these patients, radiographs were obtained and combined with radiographs from 176 patients with normal femoral fractures, to form the study cohort. All images were reviewed and classified into AFFs or normal femur fractures by 2 experts in the field (gold-standard classification) and 1 orthopedic resident educated on the specific radiographic features of AFF (educated-user classification). Furthermore, we estimated the incidence rate of AFFs in the population captured by the register through comparison with a previous cohort and calculated the positive predictive value (PPV) and, where possible, the inter-observer agreement (Cohen’s kappa) between the different classifications. Results — Of the 178 available patients with AFF in the SFR, 104 patients were classified as AFF using the goldstandard classification, and 89 using the educated-user classification. The PPV increased from 0.58 in the SFR classification to 0.93 in the educated-user classification. The interobserver agreement between the gold-standard classification and the educated-user classification was 0.81. Interpretation — With a positive predictive value of 0.58 the Swedish Fracture Register outperforms radiology reports and reports to the Swedish Medical Products Agency on adverse drug reactions as a diagnostic tool to identify atypical femoral fractures.

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Section: Discussionsupporting

confidence: 92%

Surveillance of atypical femoral fractures in a nationwide fracture register

Bögl

Zdolsek

Barnisin

et al. 2022

ActaO

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“…However, previous studies have not specified the presence or absence of other implants or sequelae in either femur prior to the index fracture. Bögl et al concluded that there was a reduced risk of subsequent hip fracture with the use of IMNs with femoral neck protection in the treatment of low energy femoral shaft fractures in a retrospective study of 897 patients, but discuss that national register data are incomplete regarding laterality [ 31 ]. Schröder et al did not review x-ray images until a subsequent femoral fracture was present [ 3 ].…”

Section: Discussionmentioning

confidence: 99%

Subsequent ipsi- and contralateral femoral fractures after intramedullary nailing of a trochanteric or subtrochanteric fracture: a cohort study on 2012 patients

Grønhaug

Dybvik

Gjertsen

et al. 2022

BMC Musculoskelet Disord

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Background The literature is inconclusive as to whether an intramedullary nail changes the distribution of a subsequent ipsi- or contralateral fracture of the femur. We have compared the incidence, localisation, and fracture pattern of subsequent femoral fractures after intramedullary nailing of trochanteric or subtrochanteric fractures in patients without previous implants in either femur at the time of surgery. Methods Retrospective analysis was performed of a two-centre cohort of 2012 patients treated with a short or long intramedullary nail for the management of trochanteric or subtrochanteric fracture between January 2005 and December 2018. Subsequent presentations with ipsi- and contralateral femoral fractures were documented. Only patients with no previous femoral surgery performed, other than the index nailing were followed. Odds ratios (ORs) for subsequent femoral fracture were calculated using robust variance estimates in logistic regression. Results The mean age of the cohort was 82.4 years and 72.1% were female. The total number of patients presenting with subsequent femoral fractures was 299 (14.9%). The number of patients presenting with subsequent ipsilateral and contralateral femoral fractures was 51 (2.5%) and 248 (12.3%) respectively (OR 5.0; CI 3.7–6.9). Twenty-six (8.7%) of all subsequent femoral fractures occured in the ipsilateral shaft, 14 (4.7%) in the ipsilateral metaphyseal area, one (0.33%) in the contralateral shaft, and three (1.0%) in the contralateral metaphysis (OR 10; CI 3.6–29). Conclusion An intramedullary nail significantly changes the fracture pattern in the event of a second low-energy trauma, reducing the risk of subsequent proximal ipsilateral femoral fractures and increasing the risk of subsequent ipsilateral femoral fractures in the shaft and distal metaphyseal area compared with the native contralateral femur.

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“…We extracted and anonymized the radiographs of 151 subjects with AFF and 230 subjects with NFF owing to their accessibility from the research PACS at Linköping University Hospital and excluding all patients with signs of previous surgery, such as joint prosthesis or other orthopedic implants, and signs of pathological fractures (Schilcher et al 2015). Fracture classification into AFF and NFF was based on repeated individual review in several previous studies with excellent interrater reliability (Schilcher et al 2011, Bogl et al 2020b. For each subject, several radiographs were available.…”

Section: Dataset and Preprocessing Proceduresmentioning

confidence: 99%

“…Early and correct diagnosis of AFF is essential for appropriate management (Bogl et al 2020a), which minimizes the risk of healing complications (Bogl et al 2020b). In clinical routine practice, conventional radiographs are used to diagnose complete AFF.…”

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Deep neural networks with promising diagnostic accuracy for the classification of atypical femoral fractures

et al. 2021

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Background and purpose — A correct diagnosis is essential for the appropriate treatment of patients with atypical femoral fractures (AFFs). The diagnostic accuracy of radiographs with standard radiology reports is very poor. We derived a diagnostic algorithm that uses deep neural networks to enable clinicians to discriminate AFFs from normal femur fractures (NFFs) on conventional radiographs. Patients and methods — We entered 433 radiographs from 149 patients with complete AFF and 549 radiographs from 224 patients with NFF into a convolutional neural network (CNN) that acts as a core classifier in an automated pathway and a manual intervention pathway (manual improvement of image orientation). We tested several deep neural network structures (i.e., VGG19, InceptionV3, and ResNet) to identify the network with the highest diagnostic accuracy for distinguishing AFF from NFF. We applied a transfer learning technique and used 5-fold cross-validation and class activation mapping to evaluate the diagnostic accuracy. Results — In the automated pathway, ResNet50 had the highest diagnostic accuracy, with a mean of 91% (SD 1.3), as compared with 83% (SD 1.6) for VGG19, and 89% (SD 2.5) for InceptionV3. The corresponding accuracy levels for the intervention pathway were 94% (SD 2.0), 92% (2.7), and 93% (3.7), respectively. With regards to sensitivity and specificity, ResNet outperformed the other networks with a mean AUC (area under the curve) value of 0.94 (SD 0.01) and surpassed the accuracy of clinical diagnostics. Interpretation — Artificial intelligence systems show excellent diagnostic accuracies for the rare fracture type of AFF in an experimental setting.

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Reduced Risk of Reoperation Using Intramedullary Nailing with Femoral Neck Protection in Low-Energy Femoral Shaft Fractures

Cited by 14 publications

References 40 publications

Surveillance of atypical femoral fractures in a nationwide fracture register

Surveillance of atypical femoral fractures in a nationwide fracture register

Subsequent ipsi- and contralateral femoral fractures after intramedullary nailing of a trochanteric or subtrochanteric fracture: a cohort study on 2012 patients

Deep neural networks with promising diagnostic accuracy for the classification of atypical femoral fractures

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