Evaluation of a treatment protocol based on conservative therapy for fragility fractures of the pelvis.

PURPOSE: In an aging society, fragility fractures of the pelvis (FFP) have increased significantly. However, there is no clear consensus on the timing and criteria for transitioning from conservative treatment to surgery for these fractures. Thus, we aimed to investigate the effects of our treatment protocol for FFP based on conservative treatment. METHODS: We conducted a retrospective study including 74 patients with FFP at our institution between 2015 and 2021. All patients were treated conservatively for the first two weeks. During this period, only wheelchair transfer was allowed. If the patient could not walk after this period, surgery was performed. Fracture type (Rommens classification), walking ability, presence of complications after admission, presence of fracture union, and surgical treatment was investigated. Patients were divided into two groups: a stable group (type I/II) and an unstable group (type III/IV). RESULTS: Fracture union was achieved in all patients. Thirteen patients developed complications after being admitted to our hospital; seven showed decreased walking ability, and six required surgeries. The stable and unstable groups comprised 47 and 27 patients, respectively. There were no statistically significant differences between the groups regarding the percentage of patients who developed complications or experienced decrease in walking ability. The percentage of patients who required surgery was significantly higher in the unstable group (p < 0.05). CONCLUSION: Our FFP management protocol was effective regardless of fracture type. It is important to provide a period for careful assessment of instability, and to try to prevent fracture progression.

Multi-institutional comparison of secondary check of treatment planning using computer-based independent dose calculation for non-C-arm linear accelerators.

PURPOSE: This report covers the first multi-institutional study of independent monitor unit (MU)/dose calculation verification for the CyberKnife, Vero4DRT, and TomoTherapy radiotherapy delivery systems. METHODS: A total of 973 clinical treatment plans were collected from 12 institutions. Commercial software employing the Clarkson algorithm was used for verification after a measurement validation study, and the doses from the treatment planning systems (TPSs) and verification programs were compared on the basis of the mean value ±â€¯two standard deviations. The impact of heterogeneous conditions was assessed in two types of sites: non-lung and lung. RESULTS: The dose difference for all locations was 0.5 ±â€¯7.2%. There was a statistically significant difference (P < 0.01) in dose difference between non-lung (-0.3 ±â€¯4.4%) and lung sites (3.5 ±â€¯6.7%). Inter-institutional comparisons showed that various systematic differences were associated with the proportion of different treatment sites and heterogeneity correction. CONCLUSIONS: This multi-institutional comparison should help to determine the departmental action levels for CyberKnife, Vero4DRT, and TomoTherapy, as patient populations and treatment sites may vary between the modalities. An action level of ±5% could be considered for intensity-modulated radiation therapy (IMRT), non-IMRT, and volumetric modulated arc radiotherapy using these modalities in homogenous and heterogeneous conditions with a large treatment field applied to a large region of homogeneous media. There were larger systematic differences in heterogeneous conditions with a small treatment field because of differences in heterogeneity correction with the different dose calculation algorithms of the primary TPS and verification program.

Decreased postoperative gluteus medius muscle cross-sectional area measured by computed tomography scan in patients with intertrochanteric fractures nailing.

BACKGROUND: In patients with femoral intertrochanteric fractures treated by cephalomedullary (CM) nailing, abduction force reportedly decreased by 25-30% during the postoperative follow-up period. The purpose of the current study is to evaluate the cross-sectional area (CSA) and adipose tissue ratio (ATR) of the gluteus medius muscle on the postoperative computed tomography (CT) view, expecting this graphic study will support clinical results. MATERIALS AND METHODS: A total of 27 patients with femoral intertrochanteric fractures treated by CM femoral nail implants completed the study. The mean age at osteosynthesis was 83 years (range: 72-94 years). The mean postoperative follow-up period was 23 months. The three CT axial slice views were defined as slices A, B, and C corresponding to proximal, midway, and distal part of gluteus medius, respectively. The CSA and ATR were assessed bilaterally. RESULTS: The mean and standard deviation of CSA values (mm2) between the nonoperated/ operated side were as follows: slice A: 2225.8 ± 621.2/1984.5 ± 425.8; slice B: 2145.1 ± 538.3/1854.9 ± 383.9; and slice C: 1711.0 ± 459.0/1434.5 ± 396.9 ( p < 0.01 in slices A, B, and C). The mean and standard deviation of ATR values (%) from the nonoperative/ operative side were as follows: slice A: 2.8 ± 1.7/5.2 ± 3.5; slice B: 2.7 ± 1.9/4.6 ± 3.2; and slice C: 3.6 ± 3.0/4.8 ± 3.2 ( p < 0.01 in slices A and B and p < 0.05 in slice C). CONCLUSION: Our image findings documented that gluteus medius is significantly changed in CSA and ATR. The damage possibly triggers decrease in muscular strength of hip abduction in the postoperative follow-up period. This measurement is objective, and needed no patient's endurance and cooperation.

Diminished abductor muscular strength in patients with valgus-impacted femoral neck fractures treated by internal fixation: Clinical study and biomechanical considerations.

BACKGROUND: Valgus-impacted femoral neck fractures treated with internal fixation occasionally result in unsatisfactory postoperative locomotive function, partially due to muscle shortening and a decrease in the moment arm. This study quantifies the degree of diminished abduction strength both clinically and biomechanically. METHODS: Fifteen patients were enrolled in this study. Twelve patients with fracture healed in valgus-impacted position were further evaluated. Muscular strength around hip was examined, and values between the nonoperated and operated side were compared and analyzed. For the biomechanical study, two three-dimensional models were prepared: model I (control model without displacement) and model II (simulated malunion of a 15° valgus-impacted fracture). Two sets of hip flexion angles in each of the models were simulated with flexion angles of 0° and 23°. RESULTS: Mean and standard deviation values for muscle strength from the nonoperative/operative side among the valgus group are as follows: flexion strength was 9.2 ± 4.0/9.2 ± 3.2, extension strength was 5.8 ± 2.8/6.1 ± 3.2, abduction strength at 0° was 9.1 ± 3.7/7.4 ± 3.6, abduction strength at 10° was 6.7 ± 3.0/5.5 ± 2.2, and knee extension strength was 15.3 ± 6.2/15.1 ± 6.0 (kgf). When comparing values between the nonoperative and operative sides, statistical significance was only observed in abduction strength ( p < 0.01). The biomechanical models prove that valgus impaction decreases the moment arm by approximately 10% at both flexion angle. CONCLUSIONS: A significant decrease in abductor strength at 0° and 10° was observed in the valgus-healed group. This may be related to a decrease in the moment arm. Further research should be done to define the acceptable limit of deformity for the satisfactory postoperative functioning.