[Garden I femoral neck fractures: conservative vs operative therapy]

Femoral Neck Fractures in Elderly Patients With Coxarthrosis and High Dislocation: The Application of Conservative Treatment

OBJECTIVE

In this study, our aim was to evaluate the results obtained by conservative treatment of femoral neck fracture in patients with untreated Crowe type 4 coxarthrosis with high dislocation.

METHODS

This was was a retrospective study done at the Orthopaedics and Traumatology Clinic in a secondary care public hospital between 2002 and 2022, in Türkiye. Femur neck fractures were evaluated in six patients who had untreated Crowe type 4 coxarthrosis with high dislocation.

RESULTS

 In the study, we had six patients with undiagnosed developmental dysplasia of the hip (DDH) who suffered femoral neck fractures. The youngest among these patients was 76 years old. Conservative treatment (bed rest, analgesics, non-steroidal anti-inflammatory drugs, and, if needed, opiates and low molecular weight heparin for antiembolic treatment) was found to reduce Harris Hip Score (HHS) and Visual Analogue Scale (VAS) scores significantly (p<0,05). Stage 1 sacral decubitus ulcer occurred in two (33.3%) patients. Patients acquired daily activity capacity similar to their situations before fracture within five to six months. None of the patients suffered embolisms and there was no union in the fracture line of the patients.  Conclusion: Based on our data, we think that conservative treatment is a remarkable option for these patients, as the complication risks are low and positive results can be obtained. Thus, we may conclude that conservative treatment can be considered in femoral neck fractures of elderly patients with DDH.

Effect of Tricalcium Phosphate on Healing of Non-Unions: An Observational Study of over 400 Non-Unions

Purpose

A central aspect of the treatment of non-unions is the filling of bone defects. The quantity of available autologous bone for this purpose is limited. Alternatively, or additionally, bone substitutes may be used. The aim of this retrospective, single-center study including 404 non-unions in 393 patients is to investigate the effect of tricalcium phosphate (TCP) on the healing of non-unions. Furthermore, the influence of gender, age, smoking status, comorbidities, type of surgical procedure, presence of infection, and length of treatment was investigated.

Methods

We evaluated three groups of patients. Group 1 received TCP + BG, group 2 received BG alone and group 3 received no augmentation. Bone stability was assessed 1 and 2 years after non-union revision surgery through analysis of radiographs using the Lane Sandhu Score. Scores ≥3 were rated as stable Other influencing factors were collected from the electronic medical record.

Results

In 224 non-unions, bone defects were filled with autologous bone and TCP (TCP+BG). In 137 non-unions, bone defects were filled with autologous bone (BG), and in 43 non-unions presenting non-relevant defects, neither autologous bone nor TCP were used (NBG). After 2 years, 72.7% of the TCP+BG patients, 90.1% of the BG patients and 84.4% of the NBG patients achieved a consolidation score ≥3. Advanced age, presence of comorbidities and longer treatment period had a significantly negative effect on consolidation 1 year after surgery. Longer treatment periods also showed a negative significant effect after 2 years. It is notable that larger defects, mainly treated with the combination of autologous bone and TCP, showed similar healing rates to that of smaller defects after 2 years.

Conclusion

The combination of TCP and autologous bone-grafts shows good results in the reconstruction of complicated bone-defects, but patience is required since the healing period exceeds 1 year in most patients.

The Role of Frailty Scores to Predict the Outcomes in Non Operative Treatment of Valgus Impacted Neck of Femur Fractures

OBJECTIVES

The management of valgus-impacted neck of femur fracture is controversial between operative and conservative treatments. This study aimed to investigate the usefulness of the Clinical frailty Score for predicting the prognosis of patients who underwent non-operative treatment for the valgus-impacted neck of femur fracture (NOF).

METHODS

A single-centred retrospective review of patients admitted with valgus impacted NOF. Data were collected from patients' records, including demographics, Clinical Frailty Score (CFS), Nottingham Hip Fracture Score (NHFS) and Abbreviated Mental Test Score (AMTS). Patients were followed up to 24 months postoperatively.

RESULTS

Fifty-eight patients who were treated non-operatively with a mean follow-up of 2.6 years met our inclusion criteria. Twenty-nine patients failed the non-operative treatment and required replacement surgeries, while 29 had successful outcomes (50%). There were no differences between the two groups' mean age and gender distributions (P 0.527 and 0.139, respectively). The successful group had significantly higher CFS (P 0.013), worse AMTS and higher mortality risk based on the NHFS (P 0.006 and P < 0.001, respectively).

CONCLUSION

This study demonstrates that CFS, AMTS and NHFS can be used as predictors when considering non-operative treatment for the valgus-impacted neck of femur fracture. Patients who are frail, demented and high risk based on the NHFS have higher success rates with non-operative treatment.

Challenging the dogma to "always operate" acute hip fractures: a proof-of-concept pilot study for nonoperative management of undisplaced femoral neck fractures

Background

The notion that all acute hip fractures are a surgical entity requiring either surgical fracture fixation or hip replacement represents a historic dogma, particularly within the orthopaedic community of the United States. The present study from a European regional trauma center was designed to challenge the notion that stable and undisplaced femoral neck fractures represent an absolute indication for surgical management.

Methods

The purpose of this study was to investigate the hypothesis that stable and undisplaced femoral neck fractures of the Garden types 1 and 2 can be safely managed nonoperatively. A retrospective observational cohort study was carried out at a regional orthopaedic trauma center in Germany from January 1, 2016 to June 30, 2021. The inclusion criteria specified patients older than 18 years suffering a < 24 h, traumatic, femoral neck fracture Garden types 1 and 2. Exclusion criteria included Garden types 3 and 4 femoral neck fractures, pregnancy, active infection or previous surgery, tumor-associated fractures, medical history of femoral neck necrosis, vascular injury associated with femoral neck fractures, nerve injury associated to a femoral neck fracture and ≥ 24 h femoral neck fracture. The primary intention of this research was to identify deterioration of fracture retention with an ensuing unplanned trip to the operating room in femoral neck fractures Garden types 1 and 2. Secondary were included unplanned readmissions and complications such as surgical site infection.

Results

A total of 41 undisplaced femoral neck fractures (Garden types 1 and 2) were included in this study; n = 20 were in the resulting admission operatively treated (group 1) and n = 21 were treated conservatively. The mean age in group 1 was 76 years; women (70%). In group 2 it was 81 years with a female dominance (71.4%). Admission status: Garden types 1 and 2, group 1 n = 13/7 and group 2 n = 15/6. Subsequent femoral neck fracture displacement (Y/N) (in case of operation, before operation) group 1 n = 14/6 and group 2 n = 6/15.

Conclusion

According with our results, patients sustaining Garden type 1 femoral neck fractures, depending on age and comorbidities, should be treated conservatively with weight bearing and under physiotherapeutic instructions. In case of femoral neck fractures Garden type 2, a surgical treatment should be performed in order to avoid femoral neck fractures to slip after weight bearing by lacking of fracture impaction.

Conservative versus surgical treatment for Garden I hip fracture: A randomized controlled trial protocol

BACKGROUND

A femoral neck fracture (FNF) is one of the most destructive and familiar injuries encountered via the orthopedic surgeons. However, this is no guideline for the treatment of the Garden I hip fractures because the current evidence is limited from the poor study design and small sample size. The objective of our research is to compare the safety and effectiveness of the surgical treatment and conservative treatment in the non-displaced FNFs.

METHODS

This is a randomized trial, which will be implemented from December 2020 to December 2021. The experiment was granted through the Research Ethics Committee of the Zhenhai District People's Hospital of Ningbo (2014005). Hundred patients meet inclusion criteria and exclusion criteria are included. Patients who are eligible for the following conditions will be included: those over 75 years old with Garden I hip fractures diagnosed by CT or X-ray. Patients with the following conditions will be excluded: patients age under 75 years old, the avascular necrosis of the femoral head, pathological fracture, infection, former symptomatic hip pathology, the history of hip fracture, as well as the lower limb deformity. The primary outcome contains pain at 1 month, 3 months and 6 months and hip function at 1 month, 3 months and 6 months. Secondary outcome includes the life quality, mortality rate, complications such as deep venous thrombosis, pulmonary embolism.

RESULTS

Comparison of outcome indicators in 2 groups after conservative treatment or surgical treatment (Table).

CONCLUSION

The current trial will offer better evidence for the future treatment selection for Garden 1 FNFs for patients older than 75years old.

TRIAL REGISTRATION NUMBER

researchregistry6147.

Poor results of functional treatment of Garden-1 femoral neck fracture in dependent patients

INTRODUCTION

Variable results are reported after functional treatment for Garden-1 femoral neck fracture, with no definite factors for failure, particularly in the absence of selection for risk. It seems well indicated in frail and/or dependent patients with comorbidities, but this has not been specifically assessed, and failure is frequent in this target population. We therefore performed a retrospective study to: (1) assess results of functional treatment for Garden-1 impacted femoral neck fracture in dependent patients, and (2) analyze survival in terms of complications and death, and related factors.

HYPOTHESIS

Functional treatment for Garden-1 fracture in dependent patients gives poor results, with a high rate of surgical revision.

MATERIAL AND METHODS

A retrospective analysis was made of Garden-1 femoral neck fracture in dependent patients (Parker score≤5), with a minimum 2 years' follow-up. One hundred and forty-six patients were included: mean age, 81.3±8.7 years (range, 55.7-99.6 years). The endpoint was survival in terms of complications requiring surgery, secondary displacement requiring surgery, excessive pain requiring surgery, non-union or femoral head osteonecrosis. Secondary endpoints were overall mortality and mortality related to complications.

RESULTS

Mean follow-up was 4.2±2.6 years (range, 2.0-10.3 years). Ninety-one of the 146 patients (62.3%) required secondary surgery: 79 (54.1%) early (<3 months post-fracture), with 77 (52.7%) secondary displacements and 2 cases (1.4%) of excessive pain; and 12 (8.2%) late (162.2±132.3 days; range, 90-454 days), with 8 (5.4%) non-unions and 4 (2.7%) osteonecroses. Mean time to onset of secondary displacement was 13.6±11.8 days (range, 0-67.0 days). Two-year survival in terms of revision surgery was 34.1% [95% CI: 26.0-42.4]. At last follow-up, 91 patients (62.3%) had died; 2-year survival in terms of death was 69.9% [95% CI: 62.4-77.3]. Survival analysis in terms of complications revealed greater mortality in absence of complications: 42 of the 55 patients (76.3%) without complications requiring surgery died, versus 49 of the 91 (53.8%) with complications requiring surgery (p=0.012); relative risk of death in absence of complications requiring surgery was 1.42 [95% CI: 1.33-5.77].

DISCUSSION

Functional treatment for Garden-1 fracture in dependent patients gave poor short- and medium-term results. Surgery is therefore recommended in this specific population; the present findings should improve survival.

LEVEL OF EVIDENCE

IV, retrospective study.

Non-operative treatment is a reliable option in over two thirds of patients with Garden I hip fractures. Rates and risk factors for failure in 298 patients

BACKGROUND

Non-operative treatment for impacted femoral neck fractures is a now rarely used strategy whose indications are controversial. No outcome predictors have been convincingly identified, in part due to the small sizes of available studies. We conducted a large retrospective study with the following objectives: (1) to evaluate the percentage of patients older than 65 years of age with non-operatively treated Garden I femoral neck fractures who experience secondary displacement, (2) to identify predictors of secondary displacement, and (3) to determine the frequency of non-operative treatment failure due to any cause and requiring joint replacement surgery.

HYPOTHESIS

Non-operative treatment is reliable in patients older than 65 years of age with Garden I femoral neck fractures.

MATERIAL AND METHODS

Approval was obtained from the French data protection authority to conduct a retrospective observational study of information in the Marseille university hospitals database. Consecutive patients who were older than 65 years of age at traumatology department admission for Garden I femoral neck fractures managed non-operatively between January 2007 and December 2017 were included. Non-operative treatment consisted in a walking test on day 1 followed by radiographs on days 2, 7, 14, 21, and 45 and after 3 and 12 months. Patients with secondary displacement underwent hip arthroplasty. Demographic data, cognitive performance, and radiological parameters were collected for each patient. We evaluated the rates of secondary displacement avascular necrosis, and non-union.

RESULTS

We included 298 patients with a mean age of 82 years (range, 65-101). Mean follow-up was 5±3 years. Secondary displacement occurred in 91 (30%) patients, at a mean of 16 days (range 2-45 days) after the fracture. Avascular necrosis of the femoral head developed in 13 (4.3%) patients and non-union in 11 (3.7%) patients. Secondary displacement was significantly associated with hypnotic treatment (OR, 4.1; 95%CI, 2.2-7.5; p=0.039), institutionalisation (OR, 6.7; 95%CI, 3.1-14.8; p=0.028), a history of repeated falls (OR, 13.5; 95%CI, 6.3-8.4; p<0.0001), having three or more comorbidities (OR, 3.2; 95%CI, 1.7-5.8; p=0.046), and having dementia (OR, 3.5; 95%CI, 1.7-6.9; p=0.0003). Secondary displacement occurred in 18 (12%) of the 151 community-dwelling patients with normal cognition and no history of repeated falls compared to 37 (75%) of the 50 institutionalised patients with dementia.

DISCUSSION

Non-operative treatment was effective in 196 (66%) of 298 patients with Garden I femoral neck fractures. Significant risk factors for secondary displacement were dementia, institutionalisation, hypnotic treatment, multiple comorbidities, and a history of repeated falls. Of 151 community-dwelling patients with normal cognition and no repeated falls, 133 (88%) achieved a full recovery with non-operative treatment alone.

LEVEL OF EVIDENCE

IV, retrospective cohort study.

A systematic review of undisplaced femoral neck fracture treatments for patients over 65 years of age, with a focus on union rates and avascular necrosis

BACKGROUND

It remains unclear whether conservative treatment should be used to treat the common undisplaced femoral neck fractures that develop in the elderly. Herein, we systematically review the rates of union and avascular necrosis after conservative and surgical treatment of undisplaced femoral neck fractures.

METHODS

We searched the EMBASE, PubMed, OVID, Cochrane Library, Web of Science, and Scopus databases for randomized controlled trials or observational studies that assessed the outcomes of conservative or surgical treatments of undisplaced femoral neck fractures. No language or publication year limitation was imposed. Statistical analyses were performed with the aid of the chi-squared test. We evaluated the quality of each publication and the risk of bias.

RESULTS

Twenty-nine studies involving 5071 patients were ultimately included; 1120 patients were treated conservatively and 3951 surgically. The union rates were 68.8% (642/933) and 92.6% (635/686) in the former and latter groups, respectively (p < 0.001). The avascular necrosis rate in the conservatively treated group was 10.3% (39/380), while it was 7.7% (159/2074) in the surgically treated group (p = 0.09).

CONCLUSIONS

Surgery to treat undisplaced femoral neck fractures was associated with a higher union rate and a tendency toward less avascular necrosis than conservative treatment.

[Femoral neck fracture]

The incidence of femoral neck fractures increases exponentially with rising age. Young patients are rarely affected but when they are it is mostly due to high energy accidents, whereas older patients suffer from femoral neck fractures by low energy trauma due to osteoporotic changes of the bone mineral density. Treatment options have not essentially changed over the last few years. Non-operative treatment may be a choice in non-dislocated and impacted fractures. Due to the high risk of secondary fracture displacement prophylactic screw osteosynthesis is recommended even in Garden type I fractures. Osteosynthetic fracture stabilization with cannulated screws or angle stable sliding screws, is usually applied in non-displaced fractures and fractures in younger patients. Older patients need rapid mobilization after surgery; therefore, total hip arthroplasty and hemiarthroplasty are commonly used with a low incidence of secondary complications. In addition to sufficient operative treatment a guideline conform osteoprosis therapy should be initiated for the prophylaxis of further fractures and patients should undertake a suitable rehabilitation.

Factors predicting secondary displacement after non-operative treatment of undisplaced femoral neck fractures

INTRODUCTION

We quantified the risk and the time of occurrence of secondary fracture displacement in non-operatively treated femoral neck fractures in our clinic, as well as investigated potential predicting patient- and fracture-related factors.

METHODS

The records of 593 patients with femoral neck fractures from January 2000 to December 2009 were reviewed. Sixty-one patients [mean age 83.0 years (SD 9.9)] with undisplaced femoral neck fractures initially received non-operative treatment. The occurrence and the time of secondary fracture displacement were documented, as well as demographics and radiological parameters. Radiographs were evaluated independently by two surgeons. Multivariable regression and Kaplan-Meier survival analyses were used.

RESULTS

Thirty-four (55.7 %) fractures showed secondary displacement occurring within the first 12 weeks after initiation of non-operative treatment. Twenty (38 %) fractures originally classified as Garden I were found to be Garden II. The risk of secondary displacement was three times higher (RR = 2.8; 95 % CI 1.7-4.8, p < 0.001) for these fractures in comparison with those confirmed as Garden I. Patients with a history of previously diagnosed osteoporosis were at a higher risk of secondary displacement as well (RR = 1.3; 95 % CI 1.0-1.5).

CONCLUSIONS

Non-operative treatment of femoral neck fractures is a treatment option, but only in well-selected cases. The majority of secondary displacements were associated with initial misdiagnosis using the Garden classification. For Garden II, primary surgical treatment is likely a better option, and therefore careful application of the Garden classification in this context is essential.

Conservative treatment of a femoral neck fracture following nail removal

With increased longevity, the management of fragility fractures in the elderly is becoming more frequent. In particular, hip fractures have considerable importance due to the significant morbidity and mortality. A 67-year-old woman underwent intramedullary nail (IMN) removal inserted for a pertrochanteric fracture that had occurred 20 months earlier. This was indicated due to continuous discomfort related to the protruding apex of the implant over the great trochanter. Due to pain persistence two days after surgery, a computed tomography (CT) scan was performed, documenting a minimally displaced impacted subcapital femoral neck fracture. Conservative management with close radiographic follow-up was conducted. After six months, the patient had returned to previous daily activities and a satisfactory range of motion was achieved without pain on walking. The purpose of our paper is to discuss the decision of removing hardware in the elderly osteoporotic patient and to analyze the possibility to conservatively treat an impacted minimally displaced subcapital fracture occurring after the removal of an IMN inserted previously for the treatment of a trochanteric fracture. In the elderly population with decreased bone quality, the removal of intramedullary implants of the proximal femur should be carefully evaluated, and osteoporotic patients undergoing reduction and fixation of femoral fractures should be encouraged to start antiosteoporotic therapy (bisphosphonate, teriparatide) to reduce the risk of further bone loss. Conservative treatment should be considered for the management of lesser symptomatic minimally displaced impacted fractures, where the inherent stability of the fracture allows rapid healing without further surgical attempts.

Complete spontaneous improvement of non-displaced femoral neck fracture without any surgery modality

Background:

Fracture of the femoral neck is still a medical dilemma due to high rates of complications and the choice of treatment. Although rigid internal fixation with cannulated screws through open or percutaneous approaches is the traditional treatment for undisplaced fractures (Garden type I and II) to avoid secondary displacement, considerable controversy still exists regarding the rate of this problem, thus it seems that a new trend in conservative management of this types of femoral neck fracture is emerging.

Case Report:

Our case is a 46-year-old woman with Garden type II femoral neck fracture, who refused all surgical options and willingly ignored her problem. Six months later she returned to our center with uneventful recovery of her fracture.

Conclusions:

The previous belief about the absolute poor prognosis of Garden type II with 100% rate of secondary displacement with non-operative management must have been an overestimation or the success histories in the literature about non-operative treatment of these fractures originates from inherited weakness of the Garden classification in differentiating type I from type II. The patient gave the informed consent prior being included into the study.