Bone callus formation is highly disrupted by dietary restriction in growing rats sustaining a femoral fracture

Abstract Purpose: To evaluate the effects of food restriction on fracture healing in growing rats. Methods: Sixty-eight male Wistar rats were assigned to two groups: (1) Control and (2) Dietary restriction. After weaning the dietary restricted animals were fed ad libitum for 42 days with 50% of the standard chow ingested by the control group. Subsequently, the animals underwent bone fracture at the diaphysis of the right femur, followed by surgical stabilization of bone fragments. On days 14 and 28 post-fracture, the rats were euthanized, and the fractured femurs were dissected, the callus was analyzed by dual-energy X-ray absorptiometry, micro-computed tomography, histomorphometry, mechanical tests, and gene expression. Results: Dietary restriction decreased body mass gain and resulted in several phenotypic changes at the bone callus (a delay in cell proliferation and differentiation, lower rate of newly formed bone and collagen deposition, reductions in bone callus density and size, decrease in tridimensional callus volume, deterioration in microstructure, and reduction in bone callus strength), together with the downregulated expression of osteoblast-related genes. Conclusion: Dietary restriction had detrimental effects on osseous healing, with a healing delay and a lower quality of bone callus formation.

Principios quirúrgicos y biomecánicos de los métodos de fijación actual en el tratamiento de fracturas de Hoffa / Surgical and biomechanical principles of current fixation methods, in treatment of Hoffa fractures

Las fracturas de los cóndilos femorales en el plano coronal (Hoffa), son lesiones que afectan directamente la biomecánica de la rodilla. Están expuestas a un factor intrínseco de inestabilidad causado por el compromiso de los ligamentos y tendones insertados al fragmento condilar fracturado y a un factor extrínseco de inestabilidad dependiente del estrés mecánico en varo/valgo durante la fase de apoyo de la marcha y movimientos de flexo-extensión. El tratamiento quirúrgico con tornillos canulados sólo permite la compresión interfragmentaria y cierto grado de estabilidad rotacional, sin embargo, ese tipo de fijación podría no ser suficiente para soportar o neutralizar las cargas. Distintos autores han publicado otros métodos de osteosíntesis con el uso de placas en el plano lateral o posterior más la colocación de tornillos en sentido postero-anterior, pero siguen siendo opciones controversiales debido al tipo de morbilidad inherente a cada constructo. El objetivo de este artículo es realizar una revisión de la literatura para analizar la validez de los principios quirúrgicos y biomecánicos en el tratamiento de fracturas tipo hoffa.

Coronal plane fractures of the femoral condyles are commonly known as Hoffa fractures. These are intraarticular fractures that directly affect the biomechanics of the knee and have intrinsic and extrinsic instability patterns. The tendons and ligaments that remain attached to the condylar fragment produce the intrinsic instability. The extrinsic instability is due to the varus/valgus stress applied during the stance phase in the gait cycle as well as the flexion-extension movements. Surgical treatment with cannulated screws only achieves interfragmentary compression and certain amount of rotational stability that is not enough to support or neutralize the loads. Some authors have published different methods of osteosynthesis with lateral or posterior plates in conjunction with screws implanted in the posterior-anterior direction, still these techniques remain controversial due to the morbidity inherent to each construct. The purpose of this article is to review the current concepts of Hoffa fractures including biomechanics and surgical principles with the intention of analyzing their treatment efficacy.

Whole-body vibration improves fracture healing and bone quality in rats with ovariectomy-induced osteoporosis

PURPOSE: To investigate the effect of vibration therapy on the bone callus of fractured femurs and the bone quality of intact femurs in ovariectomized rats. METHODS: Fifty-six rats aged seven weeks were divided into four groups: control with femoral fracture (CON, n=14), ovariectomized with femoral fracture (OVX, n=14), control with femoral fracture plus vibration therapy (CON+VT, n=14), and ovariectomized with femoral fracture plus vibration therapy (OVX+VT, n=14). Three months after ovariectomy or sham surgery, a complete fracture was produced at the femoral mid-diaphysis and stabilized with a 1-mm-diameter intramedullary Kirschner wire. X-rays confirmed the fracture alignment and fixation. Three days later, the VT groups underwent vibration therapy (1 mm, 60 Hz for 20 minutes, three times per week for 14 or 28 days). The bone and callus quality were assessed by densitometry, three-dimensional microstructure, and mechanical test. RESULTS : Ovariectomized rats exhibited a substantial loss of bone mass and severe impairment in bone microarchitecture, both in the non-fractured femur and the bone callus. Whole-body vibration therapy exerted an important role in ameliorating the bone and fracture callus parameters in the osteoporotic bone. CONCLUSION: Vibration therapy improved bone quality and the quality of the fracture bone callus in ovariectomized rats.

Avaliação do reparo ósseo por microtomografia por raio-X / Fracture healing valuation using X-ray microtomography

A microtomografia 3D por raio-X proporciona medidas quantitativas e tridimensionais da estrutura do calo eessas medidas podem potencialmente estar relacionadas com a resistência do calo. A avaliação quantitativa do reparo ósseo por meio de novas metodologias tem importante aplicação nas pesquisas experimentais relacionadas a tecnologias invasivas e não invasivas para a estimulação do mesmo. O objetivo desse estudo foi avaliar o reparo ósseo por meio da µCT em defeito ósseo em fêmur de rato. Trinta ratos machos da classe Wistar com peso médio de 300g foram divididos em grupos experimentais de 10 animais em cada grupo. Os animais foram anestesiados e um furo com 1,2mm de diâmetro foi realizada na porção medialdo fêmur utilizando-se uma broca odontológica. No 7º, 14º e 21ºpós-cirúrgico, os animais dos grupos experimentais 1, 2 e 3, respectivamente, foram sacrificados e o fêmur esquerdo excisado. Os fêmures foram envolvidos em gaze e mergulhas em solução PBS e armazenados em um saco plástico em freezer a -20º atéa análise microtomográfica. Os fêmures foram escaneados pelo microtomógrafo 1172 (SkyScan, Bélgica). Os softwares NRecon, Dataviewer, CT-Analyzer and CT-Vol, fornecidos pelo fabricantedo microtomógrafo, foram utilizados para as seguinte análises: a) análise visual das reconstruções microtomográficas dos fêmures através de secções transversais, coronais e sagitais; b) segmentação do calo ósseo nas reconstruções através de algoritmo de processamento de imagem para quantificação dos parâmetros volume total do calo ósseo (TV), volume do calo ósseo mineralizado (BV), relação BV/TV e densidade mineral óssea volumétrica do calo ósseo (BMD); c) visualização 3D do calo ósseo. A análise estatística dos parâmetros medidos utilizou o teste t de Student com um nível de significância p < 0,05. Houve um aumento estatisticamente significante nos valores dos parâmetros BV/TVe BMD na comparação entre os grupos experimentais 1 e 2...

X-ray microtomography (uCT) provides quantitative and three dimensional measurements of the callus structure and these measurements could potentially be related to callus strength. The assessment of bone repair through new methodologies hasimportant application in animal investigations regarding invasive ornon invasive technologies for the stimulation of bone healing. The aim of this investigation was the use of µCT for the assessment of bone repair in a rat femur bone defect. Thirty male Wistar rats weighting about 300g were divided in three experimental groupswith 10 animals on each group. The animals were anesthetized and a circular hole with a 1.2mm diameter was generated at the medial region of the left femur using a dental drill. At the 7th, 14th and 21st day after surgery the animals of experimental groups 1, 2 and 3, respectively, were sacrificed and the left femur excised. The femurs were wrapped in gauze immersed in phosphate-bufferedsolution and stored in a plastic bag at -20o C until the analysis bymicrotomograph. The femurs were scanned by the 1172 microtomograph(SkyScan, Belgium). The softwares NRecon, Dataviewer, CT-Analyzer and CT-Vol, provided by the microtomograph manufacture, were used for the following assessments: a) visual examination of the femurs microtomographic reconstructions usingtransversal, coronal and sagittal sections; b) segmentation of the bone callus in the reconstructions using an image processing algorithm to quantify the parameters total bone callus volume(TV), volume of the mineralized bone callus (BV), the ratio BV/TV and the volumetric bone callus mineral density (BMD); c) 3D rendering of the bone callus. The statistical analysis of themeasured parameters was performed by the Student t test with a level of significance p < 0.05. There was a statistically significant increase in the mean values of the parameters BV/TV and BMD in the comparison of experimental groups 1 and 2...

Establishment of femoral 3D finite element model and validation of injury biomechanics / 法医学杂志

OBJECTIVE@#To investigate the feasibility of creating an effective femoral finite element model from medical images of CT scan with Mimics software, and to provide a good model for femoral fracture biomechanics.@*METHODS@#CT images of femur were obtained from 16-slice spiral CT, which were subsequently imported into Mimics software according to DICOM standard. The 3D femoral finite element model was developed, meshed and assigned with material properties. The feasibility of the model was tested and validated with LS-DYNA in different modes including vertical load of 1 000 N, 3-points bending and side impacts.@*RESULTS@#Five hundred twenty-one scanning images were available and reconstructed to create a femoral finite element model consisting of 17 879 nodes and 106 834 tetrahedron elements. The average stress on the femoral neck nodes under vertical load was (3.209 7 +/- 1.373 5) MPa. Strain-deflection curve in 3-points bending test was consistent with Kennedy's study results. The results of the side impact test were in accordance with the forensic anatomical findings.@*CONCLUSION@#The established model should be applicable to femoral collision biomechanics studies.

Infecção pós-estabilização intramedular das fraturas diafisárias dos membros inferiores: protocolo de tratamento / Post-stabilization infection of lower limbs' shaft fractures: a treatment protocol

O tratamento das infecções pós-estabilização intramedular das fraturas dos membros inferiores apresenta uma grande variedade de opções, desde a limpeza cirúrgica com manutenção da haste até a retirada da haste e colocação de fixador externo. O espaçador diafisário ainda é uma técnica pouco utilizada para o tratamento desse tipo de infecção, existindo poucos relatos na literatura sobre sua aplicação. No IOT HCFMUSP, esta técnica vem sendo empregada de maneira crescente e, no presente trabalho, temos o objetivo de descrever o protocolo de tratamento utilizado em nossa instituição, bem como a apresentação de nossa casuística inicial. O protocolo consiste na antibioticoterapia endovenosa, retirada da haste intra-medular, desbridamento cirúrgico do canal medular e colocação do espaçador diafisário. Revisamos retrospectivamente o prontuário de 11 pacientes com 13 fraturas, sendo cinco femorais e oito tibiais, submetidos à técnica apresentada. O tempo de seguimento variou de 6 a 36 meses, média de 14,27 meses, com resultados satisfatórios ocorridos em dez das treze fraturas estudadas, representando uma taxa de eficácia de 76,93 por cento. Concluímos que o método representa uma boa alternativa para o tratamento destes casos, necessitando ainda novos trabalhos comparativos para a avaliação de suas vantagens e para difundir o uso do método.

Treatment of infection following intramedullary nailing of lower limbs present a large variety of options, that goes from debridement and maintenance of the nail up to the its removal and external fixation of the limb. The cement rod is an unusual technique employed for treating this kind of infection, although little is found in literature about its application. At the IOT HC-FMUSP, this technique has been increasingly employed and the purpose of this article is to describe the treatment protocol used in our institution. The protocol consists in intravenous antibiotic therapy, removal of the nail, intramedullary debridement and insertion of an antibiotic cement rod. We analyzed the history of 11 patients presenting with 13 fractures, being five femurs and eight tibias. The patients were submitted to the surgical technique described above. The time of follow up ranged from 6 to 36 months (average: 14.27 months). Satisfactory results were found in 10 of the 13 studied fractures, representing a good outcome rate (76.93 percent). We concluded that this method represents a good alternative to treatment in these cases, however further comparative studies are required in order to establish its advantages and to popularize the use of the method.

Reparação de defeitos ósseos em fêmures de ratos machos e fêmeas espontaneamente hipertensos: estudo histológico e histométrico / Bone healing in drill hole defects in spontaneously hypertensive male and female rats' femurs: a histological and histometric study

OBJETIVO: O objetivo deste estudo foi avaliar a reparação óssea em ratos espontaneamente hipertensos (SHR) e compará-la com a de ratos normotensos, avaliando machos e fêmeas. MÉTODOS: Um defeito ósseo foi criado no fêmur esquerdo de 24 SHR (12 machos e 12 fêmeas) e 24 ratos normotensos (12 machos e 12 fêmeas). Os animais foram divididos em dois grupos com diferentes períodos de sacrifício: sete e 21 dias após o procedimento cirúrgico. Após processamento laboratorial de rotina, as análises histológica e histométrica foram realizadas e os dados submetidos à análise de variância (ANOVA) e ao teste de Tukey (5 por cento). RESULTADOS: Machos e fêmeas do mesmo grupo apresentaram características histológicas similares. Após sete dias, todos os animais apresentaram trabéculas ósseas irregulares, entretanto, os osteoblastos periosteais eram achatados nos SHR, enquanto nos normotensos, essas células apresentavam formato cúbico. Após 21 dias, todos os espécimes mostraram fechamento linear em toda a extensão superficial do defeito ósseo e os SHR apresentaram osteoblastos achatados, enquanto os normotensos apresentaram células cúbicas circundando as trabéculas ósseas. A análise estatística dos dados histométricos indicou médias similares entre machos e fêmeas, exceto para ratos normotensos, aos sete dias. Além disso, aos 21 dias, foi observada maior neoformação óssea nos ratos hipertensos quando comparados aos normotensos, tanto machos quanto fêmeas. CONCLUSÃO: Concluiu-se que os animais SHR apresentaram maior neoformação e maturidade óssea nos defeitos que animais normotensos, no período de 21 dias após a cirurgia.

OBJECTIVE: The aim of this study was to evaluate the bone healing in spontaneously hypertensive rats (SHR) and compare the results with normotensive rats, evaluating male and female animals. METHODS: A bone drill defect was created in the left femur of 24 SHR (12 males and 12 females) and 24 normotensive rats (12 males and 12 females). The animals were divided into two groups and sacrificed 7 and 21 days after the surgical procedure. After the routine laboratory processing, histological and histometric analysis were carried out and data were submitted to ANOVA and TukeyÆs test (5 percent). RESULTS: Males and females from the same group had similar histological characteristics. After seven days, all animals presented irregular bone trabeculae. The periosteal osteoblasts were flattened in SHR, and presented a cuboid shape in normotensive animals. After 21 days, the bone defects of all specimens showed a linear closure in all the superficial extension. In addition, SHR presented flattened osteoblasts surrounding the bone trabeculae, while normotensive ones showed cuboidal cells. Statistical analysis of the histometric data indicated similar means between the male and female groups, except for normotensive rats on day 7. In addition, a larger amount of new bone formation was observed in hypertensive when compared to normotensive rats on day 21, in males as well as females. CONCLUSION: We conclude that bone healing in SHR was more significant than in normotensive ones, as shown by the histological and histometric evaluation 21 days after surgery.

Análise de fraturas diafisárias do fêmur em crianças menores de 3 anos de idade / Femoral shaft fractures: an assessment in children younger than 3 years old

Este estudo consiste na reavaliação ortopédica e psicossocial de crianças que sofreram fratura do fêmur até a idade dos três anos e objetiva a análise de suas causas prováveis e detecção de indícios de ocorrência de Síndrome de Maus Tratos. Trinta e cinco crianças menores de três anos de idade sofreram fratura diafisária de fêmur e foram atendidas no Pronto Socorro do Serviço de Ortopedia e Traumatologia da Santa Casa de São Paulo, no período de janeiro de 1996 a agosto de 2002, sendo que 18 compareceram para reavaliação. Como causa relatada das fraturas observamos: queda em 13 (72,2 por cento) casos, queda de objetos sobre o membro em três (16,7 por cento) e fratura no parto em dois (11,1 por cento). Constatamos suspeita de Síndrome dos Maus Tratos em nove (maus tratos físicos em seis [33,3 por cento] e negligência em três [16,7 por cento]) casos, fratura patológica em quatro (22,2 por cento), causa acidental em três (16,7 por cento), e outras causas em dois (11,1 por cento) casos. Maus tratos constituem uma importante causa a ser investigada nos casos de fratura do fêmur em crianças com menos de três anos de idade, sendo o provável mecanismo responsável por metade das fraturas aqui estudadas.

This study consists of an orthopaedic and psychosocial re-evaluation of children who experienced femur fractures as young as 3 years old and aims to analyze potential causes and detect Child Abuse rates. Thirty-five children under the age of three years who experienced femoral shaft fractures received care at the Emergency Department of the Orthopaedics and Traumatology Service of Santa Casa de São Paulo within the period ranging from January, 1996 to August, 2002. Eighteen patients returned to the hospital for re-evaluation. The reported causes for fractures were: fall in 13 cases (72.2 percent), object fall on the limb in 2 cases (11.1 percent). Child abuse was suspected in 9 cases (physical abuse in 6 cases (33.3 percent), negligence in 3 cases (16.7 percent), pathological fracture in 4 cases (22.2 percent), accidental causes in 3 cases (16.7 percent), and other causes in 2 cases (11.1 percent). Child abuse constitutes an important cause that needs to be investigated in cases of femur fracture in children under the age of three years and this has possibly been the mechanism responsible for half of the fractures investigated in the current study.

Fratura simultânea bilateral do colo do fêmur / Simultaneous bilateral femoral neck fracture

Fratura simultânea bilateral do colo do fêmur é uma patologia rara e geralmente está relacionada a doenças metabólicas ou outras patologias prévias. Esse tipo de fratura pode passar despercebida, piorando o prognóstico desses pacientes. Neste relato, os autores apresentam o caso de um paciente do sexo masculino de 27 anos de idade com fratura simultânea bilateral do colo do fêmur após um episódio de convulsão. Serão discutidos aspectos sobre o mecanismo do trauma, os tipos de tratamento e a dificuldade no dianóstico nesse tipo de fratura.

Plate-screw-wiring technique for the treatment of periprosthetic fracture around the hip: a biomechanical study.

Biomechanic properties, bending stiffness and torsional strength, were determined in three different fixation techniques including lateral plating, lateral plating with cerclage wires, and 90 degrees-90 degrees anterior and lateral plating employed in treatment of the femoral shaft fracture with the presence of a femoral prosthesis. Five pairs of human femora with a man made cemented periprosthetic Johansson et al fracture classification type II were used in the experiments. The study showed that 90 degrees-90 degrees anterior and lateral plating produced the best increment in both biomechanic properties. In clinical practice, most of the soft tissue around femoral bone had to be dissected to do this technique, which would affect bone healing. Further study regarding the other properties, benefits, and disadvantages of these three techniques should be conducted before selecting the best method for treatment of the patients.

Endoscopic bone graft for delayed union and nonunion

We performed endoscopic bone grafting for eight patients of delayed union and nonunion which developed after femoral and humeral shaft fractures. The mean interval from initial intervention to endoscopic bone grafting was 7.3 months. Six patients of delayed union and nonunion healed at 4.1 months on average. Two patients had unsatisfactory healing and eventually underwent non-endoscopic revisional surgery. There was no intraoperative on postoperative complication. Endoscopic bone grafting can be a less invasive alternative, obtaining rapid bone union in cases of compromised healing of the diaphyseal fracture.

Manejo e incidencia de las complicaciones en las fracturas de la diáfisis femoral

Se realizó un estudio descriptivo observacional serie de casos, controlando los pacientes con fracturas de la diáfisis femoral, abiertas o cerradas, que fueron tratados en el Departamento de Ortopedia y Traumatología del Hospital Universitario del Valle, con difernetes métodos de acuerdo a 1) la personalidad de la fractura; 2) compromiso de las partes blandas y 3) recursos disponibles en la institución. Se trataron 646 pacientes con 659 fracturas (13 casos bilaterales) y solamente se pudo realizar un seguimiento en 400 pacientes con 408 fracturas; analizamos los tratamientos efectuados y las complicaciones presentadas. El sexo que predominó fue el masculino en más del 60 por ciento de los casos; la edad más frecuente fue entre los 20 y 29 años; el lado izquierdo fue el más lesionado y los accidentes de tránsito fueron la primera causa de fractura en el 70 por ciento. Las fracturas más complejas en la clasificación de Winquist, las Grado II, III y IV, ocuparon el 76 por ciento y se destaca ademas un porcentaje elevado de fracturas abiertas (25 por ciento). El tiempo entre fractura y la estabilización fue en promedio de 8 días. El clavo intramedular bloqueado fue fue el implante más utilizado (41 por ciento). La consolidación de las fracturas se obtuvo a las 20 semanas en 93 por ciento de los casos. El implante con mayor número de éxito y menor número de complicaciones fue el clavo bloqueado con técnica cerrada.

Pulsed electromagnetic fields for the treatment of bone fractures.

The effectiveness of electrical stimulation and Pulsed Electro Magnetic Field (PEMF) stimulation for enhancement of bone healing has been reported by many workers. The mechanism of osteogenesis is not clear, therefore, studies look for empirical evidence. The present study involved a clinical trial using low amplitude PEMF on 19 patients with non-union or delayed union of the long bones. The pulse system used was similar in shape to Bassett's single pulse system where the electric voltage pulse was 0.3 mSec wide repeating every 12 mSec making a frequency of about 80 Hz. The peak magnetic fields were of the order of 0.01 to 0.1 m Tesla, hundred to thousand times smaller than that of Bassett. Among the 13 who completed this treatment schedule the history of non-union was an average of 41.3 weeks. Within an average treatment period of 14 weeks, 11 of the 13 patients had successful bone healing. The two unsuccessful cases had bone gaps greater than 1 cm following removal of dead bone after infection. However, use of such a low field negates Bassett's claim for a narrow window for shape and amplitude of wave form, and justifies further experimental study and an attempt to understand the underlying mechanism.

Evaluación del tratamiento del tercio proximal de fémur en los años 1986 a 1995, en el Hospital de Apoyo Goyeneche

En el presente trabajo de investigación se estudió 103 historias clínicas de pacientes con diagnóstico de fractura de tercio proximal de fémur en el Hospital de Apoyo Goyeneche, se hizo seguimiento clínico a 66 pacientes y seguimiento radiográfico a 11 pacientes. Por considerar de importancia estudiamos otros aspectos más relacionados con el objetivo principal. Encontramos que en la incidencia por años hubo un aumento progresivo de la misma aunque con algunos altibajos. En cuanto a la incidencia por grupos etáreos se encontró una gran incidencia a partir de los 60 años (50 por ciento), con cifras considerables por debajo de los 30 años, siendo el sexo más afectado el masculino representando las 3/5 partes de la población total. No se encontró diferencias significativas en el estudio del lado afectado. La causa más frecuente de esta patología son traumas menores (60.20 por ciento), seguidos de traumas mayores (34 por ciento) y un porcentaje menor de fracturas por arma de fuego y neoplasias. En este trabajo revisamos todos los diagnósticos de fractura de fémur y estudiamos todos los diagnósticos de fractura de tercio proximal de fémur. Se encontró una mayor incidencia con este último diagnóstico (46.38 por ciento) predominando sobre los otros dos tercios (medio y distal). La localización anatómica más frecuente fue la intertrocantérica con 35.63 por ciento, seguida de la intracapsular con 28.16 por ciento y la subtrocantérica con 26.21 por ciento. Los trazos fracturarios más frecuentes en las fracturas intracapsulares fueron el subcapital y el basicervical. Las fracturas subtrocantéricas tubieron sus más altas incidencias en los primeros 30 años, lo mismo sucedió con la clasificación de Evans modificada donde el grado 3 predominó con 59.57 por ciento, de acuerdo con la clasificación de Sensheimer los resultados fueron más dispersos siendo el más frecuente el grado 2 con 37.04 por ciento, seguido del grado 1 con 29.63 por ciento y el grado 3 con 25.93 por ciento. Los tipos de tratamiento más utilizados en el tratamiento de las fracturas intracapsulares fueron la tracción cutánea con 27.59 por ciento seguida de la endoprótesis de Thompson con 20.69 por ciento y la operación de Girdlestone con 17.25 por ciento. En las fracturas intertrocantéricas las placas anguladas fueron las más utilizadas con 44.69 por ciento seguida de la tracción cutánea con 23.40 por ciento. El otro tratamiento bastante utilizado fue la tracción esquelética. En las fracturas subtrocantéricas los tratamientos más utilizados fueron la tracción cutánea y el clavo kuntscher. Los resultados globales de seguimientos dieron como resultado a 33.34 por ciento calificado como excelente, 39.39 por ciento calificado como bueno, 18.18 por ciento calificado como satisfactorio y un 9.09 por ciento como no satisfactorio. Los resultados excelente y bueno tubieron una predominancia absoluta por debajo de los 60 años y a partir de esa edad se observa un gran incremento de los calificativos de satisfactorio y no satisfactorio. Respecto a la localización anatómica, la localización intracapsular muestra a un 31.58 por ciento con calificativo de no satisfactorio. La localización subtrocantérica muestra los mejores resultados seguida de la intertrocantérica. De acuerdo a la clasificación de Temple encontramos un incremento de los resultados no satisfactorios a medida que aumentan los grados. En la clasificación de Evans Modificada no se encuentran los calificativos satisfactorios a medida que aumentan los grados. En la clasificación Sensheimer se encontró con el grado 1 todos los resultados excelentes este calificativo disminuye a medida que aumentan los grados...