Avascular femoral head necrosis following fracture fixation

Comparison of the Surgical Outcome between the Multiple Screw Fixation and Fixed Angle Devices for the Basicervical Femoral Neck Fractures

Introduction: Basicervical femoral neck fracture (FNF) is an uncommon type of femoral neck fracture and is associated with an increased risk of fixation failure due to its inherent instability. The purpose of this study was to compare the surgical parameters and reoperation rate between the use of a multiple cannulated screw (MCS) and fixed angle device (FAD) in treating basicervical FNFs. Methods: We retrospectively reviewed the records of 885 patients who underwent internal fixation between May 2004 and August 2019 to determine basicervical FNF with at least 12 months of follow-up. Among the identified 77 patients with basicervical FNF, 17 patients who underwent multiple cannulated screw (MCS) fixation and 36 patients who underwent fixed angle device (FAD) fixation were included. We compared the rates of fracture-site collapse and reoperations according to the fixation device. Results: Among the 53 patients with basicervical FNF, 13 patients (24.5%) sustained surgical complications (8 collapses of fracture site and 5 reoperations). The reoperation rate in the MCS group was significantly higher than that in the FAD group (23.5% vs. 2.8%, p = 0.016), without any significant difference in the collapse of the fracture site (11.8% vs. 16.7%, p = 0.642). Conclusions: Although basicervical FNF was rare among hip fractures, fracture site collapse was prevalent and prone to fixation failure. Surgeons should keep this in mind, and consider FAD for basicervical FNF.

Open reduction and internal fixation of irreducible displaced femoral neck fracture with femoral Neck System: a preliminary study

BACKGROUND

Most displaced femoral neck fractures can achieve satisfactory anatomical reduction by closed reduction, but there are still some that cannot reset satisfactorily after closed reduction, and open reduction are required. Such fractures that cannot be repositioned successfully by closed reduction are called irreducible displaced femoral neck fractures in this study. The objective of our study was to evaluate the efficacy of direct anterior incision with the Femoral Neck System in the treatment of irreducible displaced femoral fractures.

METHODS

A total of 16 young and middle-aged patients with irreducible displaced femoral neck fractures involving Garden type III and IV were treated using Femoral Neck System fixation by open reduction through Direct Anterior Approach between January 2020 to September 2021. Functional outcomes and postoperative complications were assessed during follow-up. Clinical outcomes were evaluated by the Hip Harris score. The postoperative reduction was evaluated by the Garden Index. Observe postoperative complications.

RESULTS

All patients were followed up with a mean follow-up time of 21.1(12-30) months, and according to radiological results, all patients achieved fracture healing, with a mean healing time of 4.25 months. All 16 patients received grade Garden I and II reductions, and there was no significant difference in the anteroposterior Garden reduction index between the first day after surgery (166.13 ± 5.61) and the 12th month after surgery(164.94 ± 4.49) (P>0.05) and no significant difference in lateral Garden index between the first day after surgery(171.06 ± 4.46) and the 12th month after surgery(169.38 ± 3.98) (P<0.05). According to the Hip Harris score scale, 13 patients received excellent and 3 patients received good. The postoperative Hip Harris Score(17.19 ± 4.8) was significantly higher than the preoperative score(92.19 ± 3.4), and the difference was statistically significant (P < 0.05). No or mild femoral neck shortness occurred in 12 (75%) patients, moderate shortening occurred in 3 (18.75%) patients, and severe shortening occurred in 1 (6.25%) patient. None of the patients experienced femoral head necrosis, fracture nonunion, or incision infection. One patient developed deep venous thrombosis of the lower extremity.

CONCLUSIONS

The Direct Anterior Approach combined with Femoral Neck System is an excellent treatment for irreducible displaced femoral neck fracture and achieved good functional outcomes and anatomical reduction with low complications.

Restoration of Hip Geometry after Femoral Neck Fracture: A Comparison of the Femoral Neck System (FNS) and the Dynamic Hip Screw (DHS)

BACKGROUND

The femoral neck system (FNS) was introduced as a minimally invasive fixation device for managing femoral neck fractures.

OBJECTIVE

To compare radiographic, clinical, and patient-reported outcome measures (PROMs) of femoral neck fracture patients following FNS compared to dynamic hip screw (DHS) implantation combined with an anti-rotational screw.

METHODS

Patients who underwent closed reduction and internal fixation of a femoral neck fracture between 2020 and 2022 were retrospectively included. We measured leg length, femoral offset, and centrum-collum-diaphyseal (CCD) angle in plain radiographs. Scar length, Harris Hip Score, short-form health survey 36-item score (SF-36), and Numeric Rating Scale (NRS) were assessed during follow-up visits.

RESULTS

We included 43 patients (22 females) with a median age of 66 (IQR 57, 75). In both groups, leg length differences between the injured and the contralateral side increased, and femoral offset and CCD angle differences were maintained over time. FNS patients had shorter scars and reported fewer emotional problems and more energy. There were no differences between groups regarding the remaining SF-36 sub-scores, Harris Hip Score, and NRS.

CONCLUSIONS

The FNS allows for a comparable leg length, femoral offset, and CCD angle reconstruction while achieving similarly high functional and global health scores to the DHS.

High Percentage of Complications and Re-Operations Following Dynamic Locking Plate Fixation with the Targon® FN for Intracapsular Proximal Femoral Fractures: An Analysis of Risk Factors

The ideal surgical treatment of femoral neck fractures remains controversial. When treating these fractures with internal fixation, many fixation constructs exist. The primary aim of this study was to evaluate the incidence and specific risk factors associated with complication and re-operation following fixation of intracapsular proximal femoral fractures using the Targon-FN system (B.Braun Melsungen AG). A secondary aim was to identify if lateral prominence of the implant relative to the lateral border of the vastus ridge was a specific risk factor for elective plate removal. Methodically, a retrospective case series was conducted of all consecutive adult patients treated at a single level 1 trauma center in Switzerland for an intracapsular proximal femoral fracture with the Targon-FN. Demographic data were collected. Patients with a follow-up of less than three months were excluded. Complications as well as plate position were recorded. Statistical analysis to identify specific risk factors for re-operation and complications was performed. In result, a total of 72 cases with intracapsular femoral neck fractures were treated with the Targon-FN locking plate system between 2010 and 2017. Thirty-four patients (47.2%) experienced one or more complications. The most common complication was mechanical irritation of the iliotibial band (ITB) (23.6%, n = 17). Complications included intraarticular screw perforation (6.9%, n = 5), avascular necrosis (5.6%, n = 4), non-union (5.6%, n = 4) among others. In total, 46 re-operations were required. Younger age, fracture displacement and time to postoperative weight bearing were identified as risk factors for re-operation. In conclusion, intracapsular femoral neck fractures treated with the Targon-FN system resulted in a high rate of post-operative complication and re-operation. Statistical analysis revealed patient age, fracture displacement, time to postoperative full weight bearing were risk factors for re-operation. The main limitation is the limited number of cases and a short follow-up of less than 12 months in a subgroup of our patients.

Avascular Necrosis of Femoral Head-Overview and Current State of the Art

Avascular necrosis (AVN) of the femoral head is caused by disruption of the blood supply to the proximal femur. The alterations in the blood supply may occur following a traumatic event or result from a non-traumatic cause. Femoral neck fracture and hip dislocation and associated surgical procedures, corticosteroid therapy, and alcohol abuse frequently lead to AVN development. Type of fracture (displaced or undisplaced) and time between injury and surgery are the most critical factors in assessing the risk of developing AVN. Diagnosis of AVN can be established based on patients’ complaints, medical history, and radiographic findings. There is no consensus on the treatment of patients with AVN to date. Non-surgical methods are dedicated to patients in the early pre-collapse stages of the disease and consist of pharmacotherapy and physiotherapy. Surgery is recommended for patients with advanced disease.

Curative efficacy of surgical procedures for older patients with femoral neck fracture: a network meta-analysis and systematic review

BACKGROUND

Femoral neck fractures have a higher incidence in older people with poor prognosis, inducing serious social problems. Common treatment methods include total hip arthroplasty, bipolar hemiarthroplasty, double-screw fixation, multiple-screw fixation, and dynamic hip system.

METHODS

We searched through four electronic databases, including PubMed, Web of Science, Cochrane Library, and Embase databases, for articles regarding femoral neck fractures, bone screw, and hip prosthesis published up to February 11, 2020. All included articles were used for quality evaluation and data extraction. Extracted data were expressed as odds ratios or weighted mean differences, with 95% confidence intervals. We conducted a network meta-analysis for Harris hip score, complications, 1-year mortality rate, reoperation rate, intraoperative blood loss, and duration of operation using STATA version 16.0 software.

RESULTS

Twenty-two randomized controlled trials and nine cohort studies included in this study involved 3861 patients. Total hip arthroplasty significantly improved the postoperative function of patients with femoral neck fractures. The surface under the cumulative ranking curve value of the Harris hip score for more than 1 year after total hip arthroplasty was 98.2.

CONCLUSIONS

This meta-analysis indicated no significant difference in mortality among different treatment groups. Total hip arthroplasty can provide satisfactory outcomes in hip joint function, and double-screw fixation results in the lowest intraoperative risk. In general, total hip arthroplasty results in a lower incidence of adverse events and is especially recommended for patients with femoral neck fractures. This article has been retrospectively registered on the International Platform of Registered Systematic Review and Meta-analysis Protocols (INPLASY) on November 27, 2020. Registration number: INPLASY2020110123.

Comparing Perioperative Outcome Measures of the Dynamic Hip Screw and the Femoral Neck System

Background and Objective: Various fixation devices and surgical techniques are available for the management of proximal femur fractures. Recently, the femoral neck system (FNS) was introduced, and was promoted on the basis of less invasiveness, shorter operating time, and less fluoroscopy time compared to previous systems. The aim of this study was to compare two systems for the internal fixation of femoral neck fractures (FNF), namely the dynamic hip screw (DHS) with an anti-rotation screw (ARS) and an FNS. The outcome measures included operating room time (ORT), dose−area product (DAP), length of stay (LOS), perioperative changes in haemoglobin concentrations, and transfusion rate. Materials and Methods: A retrospective single-centre study was conducted. Patients treated for FNF between 1 January 2020 and 30 September 2021 were included, provided that they had undergone closed reduction and internal fixation. We measured the centrum-collum-diaphyseal (CCD) and the Pauwels angle preoperatively and one week postoperatively. Results: In total, 31 patients (16 females), with a mean age of 62.81 ± 15.05 years, were included. Fracture complexity assessed by the Pauwels and Garden classification did not differ between groups preoperatively. Nonetheless, the ORT (54 ± 26.1 min vs. 91.68 ± 23.96 min, p < 0.01) and DAP (721 ± 270.6 cGycm² vs. 1604 ± 1178 cGycm², p = 0.03) were significantly lower in the FNS group. The pre- and postoperative CCD and Pauwels angles did not differ statistically between groups. Perioperative haemoglobin concentration changes (−1.77 ± 1.19 g/dl vs. −1.74 ± 1.37 g/dl) and LOS (8 ± 5.27 days vs. 7.35 ± 3.43 days) were not statistically different. Conclusions: In this cohort, the ORT and DAP were almost halved in the patient group treated with FNS. This may confer a reduction in secondary risks related to surgery.

Surgical interventions for treating intracapsular hip fractures in older adults: a network meta-analysis

BACKGROUND

Hip fractures are a major healthcare problem, presenting a considerable challenge and burden to individuals and healthcare systems. The number of hip fractures globally is rising rapidly. The majority of intracapsular hip fractures are treated surgically.

OBJECTIVES

To assess the relative effects (benefits and harms) of all surgical treatments used in the management of intracapsular hip fractures in older adults, using a network meta-analysis of randomised trials, and to generate a hierarchy of interventions according to their outcomes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Web of Science, and five other databases in July 2020. We also searched clinical trials databases, conference proceedings, reference lists of retrieved articles and conducted backward-citation searches.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs comparing different treatments for fragility intracapsular hip fractures in older adults. We included total hip arthroplasties (THAs), hemiarthroplasties (HAs), internal fixation, and non-operative treatments. We excluded studies of people with hip fracture with specific pathologies other than osteoporosis or resulting from high-energy trauma.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion. One review author completed data extraction which was checked by a second review author. We collected data for three outcomes at different time points: mortality and health-related quality of life (HRQoL) - both reported within 4 months, at 12 months, and after 24 months of surgery, and unplanned return to theatre (at end of study follow-up). We performed a network meta-analysis (NMA) with Stata software, using frequentist methods, and calculated the differences between treatments using risk ratios (RRs) and standardised mean differences (SMDs) and their corresponding 95% confidence intervals (CIs). We also performed direct comparisons using the same codes.

MAIN RESULTS

We included 119 studies (102 RCTS, 17 quasi-RCTs) with 17,653 participants with 17,669 intracapsular fractures in the review; 83% of fractures were displaced. The mean participant age ranged from 60 to 87 years and 73% were women.  After discussion with clinical experts, we selected 12 nodes that represented the best balance between clinical plausibility and efficiency of the networks: cemented modern unipolar HA, dynamic fixed angle plate, uncemented first-generation bipolar HA, uncemented modern bipolar HA, cemented modern bipolar HA, uncemented first-generation unipolar HA, uncemented modern unipolar HA, THA with single articulation, dual-mobility THA, pins, screws, and non-operative treatment. Seventy-five studies (with 11,855 participants) with data for at least two of these treatments contributed to the NMA. We selected cemented modern unipolar HA as a reference treatment against which other treatments were compared. This was a common treatment in the networks, providing a clinically appropriate comparison. In order to provide a concise summary of the results, we report only network estimates when there was evidence of difference between treatments. We downgraded the certainty of the evidence for serious and very serious risks of bias and when estimates included possible transitivity, particularly for internal fixation which included more undisplaced fractures. We also downgraded for incoherence, or inconsistency in indirect estimates, although this affected few estimates. Most estimates included the possibility of benefits and harms, and we downgraded the evidence for these treatments for imprecision.  We found that cemented modern unipolar HA, dynamic fixed angle plate and pins seemed to have the greatest likelihood of reducing mortality at 12 months. Overall, 23.5% of participants who received the reference treatment died within 12 months of surgery. Uncemented modern bipolar HA had higher mortality than the reference treatment (RR 1.37, 95% CI 1.02 to 1.85; derived only from indirect evidence; low-certainty evidence), and THA with single articulation also had higher mortality (network estimate RR 1.62, 95% CI 1.13 to 2.32; derived from direct evidence from 2 studies with 225 participants, and indirect evidence; very low-certainty evidence). In the remaining treatments, the certainty of the evidence ranged from low to very low, and we noted no evidence of any differences in mortality at 12 months.  We found that THA (single articulation), cemented modern bipolar HA and uncemented modern bipolar HA seemed to have the greatest likelihood of improving HRQoL at 12 months. This network was comparatively sparse compared to other outcomes and the certainty of the evidence of differences between treatments was very low. We noted no evidence of any differences in HRQoL at 12 months, although estimates were imprecise. We found that arthroplasty treatments seemed to have a greater likelihood of reducing unplanned return to theatre than internal fixation and non-operative treatment. We estimated that 4.3% of participants who received the reference treatment returned to theatre during the study follow-up. Compared to this treatment, we found low-certainty evidence that more participants returned to theatre if they were treated with a dynamic fixed angle plate (network estimate RR 4.63, 95% CI 2.94 to 7.30; from direct evidence from 1 study with 190 participants, and indirect evidence). We found very low-certainty evidence that more participants returned to theatre when treated with pins (RR 4.16, 95% CI 2.53 to 6.84; only from indirect evidence), screws (network estimate RR 5.04, 95% CI 3.25 to 7.82; from direct evidence from 2 studies with 278 participants, and indirect evidence), and non-operative treatment (RR 5.41, 95% CI 1.80 to 16.26; only from indirect evidence). There was very low-certainty evidence of a tendency for an increased risk of unplanned return to theatre for all of the arthroplasty treatments, and in particular for THA, compared with cemented modern unipolar HA, with little evidence to suggest the size of this difference varied strongly between the arthroplasty treatments.

AUTHORS' CONCLUSIONS

There was considerable variability in the ranking of each treatment such that there was no one outstanding, or subset of outstanding, superior treatments. However, cemented modern arthroplasties tended to more often yield better outcomes than alternative treatments and may be a more successful approach than internal fixation. There is no evidence of a difference between THA (single articulation) and cemented modern unipolar HA in the outcomes measured in this review. THA may be an appropriate treatment for a subset of people with intracapsular fracture but we have not explored this further.

Parallel and non-parallel cannulated screw fixation complications in femoral neck fractures: A systematic review and meta-analysis

BACKGROUND

Since its introduction in the early 1960s, the multiple cannulated screw fixation method has been developed for use in femoral neck fractures (FNFs); however, the parallelism of screws remains controversial.

MATERIALS AND METHODS

MEDLINE, Embase, and the Cochrane Library were systematically searched for studies published before June 2, 2020, that compared the use of parallel and non-parallel screw fixation for the treatment of FNF. The pooled analysis was designed to identify differences between the two groups and focused on postoperative complications, including fracture nonunion and osteonecrosis of the femoral head (ONFH).

RESULTS

Over four studies, we enrolled 445 patients, including 195 patients with fixed FNF with parallel trajectory screws and 250 patients with fixed FNF with non-parallel screws. The pooled analysis showed no difference in the nonunion rates (odds ratio (OR)=0.91; 95% confidence interval (CI), 0.24-3.44; p=0.89) and no significant difference in the incidence of ONFH between parallel and non-parallel screw fixation (OR=0.74; 95% CI: 0.21-2.63; p=0.64).

CONCLUSIONS

The results of this meta-analysis reveal that screw parallelism in multiple cannulated screw fixation of FNF has no relationship with either the fracture nonunion rate or the incidence of postoperative ONFH.

LEVEL OF EVIDENCE

III; meta-analysis.

Femoral neck system versus inverted cannulated cancellous screw for the treatment of femoral neck fractures in adults: a preliminary comparative study

BACKGROUND

The femoral neck system (FNS) may be a valid alternative for treating femoral neck fractures, but few studies have compared the outcomes between FNS and cannulated cancellous screws. This study aimed to compare the clinical efficacy and complications of FNS with those of inverted cannulated cancellous screws (ICCS) for the treatment of femoral neck fractures in adults.

METHODS

This retrospective study evaluated patients with femoral neck fractures who underwent FNS or ICCS internal fixation between June 2019 and January 2020. The operative time, intraoperative blood loss, number of fluoroscopies, length of surgical incision, length of hospital stay, time to fracture healing, and other indicators were compared between the two groups. The incidence of complications such as nonunion, avascular necrosis of the femoral head, loosening of the internal fixation, and shortening of the femoral neck during follow-up was also assessed in both groups.

RESULTS

Among the 92 patients included, 47 and 45 patients were categorized into the FNS and ICCS groups, respectively. Follow-up ranged from 14 to 24 months. There were no significant between-group differences in sex, age, side of the injured limb, and type of fracture and in operative time, intraoperative blood loss, incision length, and length of hospital stay (all P > 0.05). The incidence of complications such as fracture nonunion, avascular necrosis of the femoral head, and screw loosening was also comparable between the two groups. However, the number of fluoroscopies was significantly lower in the FNS group than in the ICCS group (P < 0.05). The fracture healing time was also significantly lower in the FNS group than in the ICCS group (P < 0.05). Furthermore, the femoral neck shortening and Harris hip score at the last follow-up were significantly better in the FNS group than in the ICCS group (P < 0.05).

CONCLUSIONS

FNS for femoral neck fractures improves hip functional recovery and reduces the femoral neck shortening rate and fluoroscopy exposure postoperatively. Thus, FNS can be an alternative to ICCS for the treatment of femoral neck fractures.

Internal fixation implants for intracapsular hip fractures in older adults

BACKGROUND

Hip fractures are a major healthcare problem, presenting a huge challenge and burden to patients, healthcare systems and society. The increased proportion of older adults in the world population means that the absolute number of hip fractures is rising rapidly across the globe. The majority of hip fractures are treated surgically. This review evaluates evidence for types of internal fixation implants used in joint-preserving surgery for intracapsular hip fractures.

OBJECTIVES

To determine the relative effects (benefits and harms) of different implants for the internal fixation of intracapsular hip fractures in older adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Web of Science, Cochrane Database of Systematic Reviews, Epistemonikos, Proquest Dissertations and Theses, and National Technical Information Service in July 2020. We also searched clinical trials databases, conference proceedings, reference lists of retrieved articles and conducted backward-citation searches.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs comparing implants used for internal fixation of fragility intracapsular proximal femoral fractures in older adults. Types of implants were smooth pins (these include pins with fold-out hooks), screws, or fixed angle plates. We excluded studies in which all or most fractures were caused by specific pathologies other than osteoporosis or were the result of a high energy trauma.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion. One review author extracted data and assessed risk of bias which was checked by a second review author. We collected data for seven outcomes: activities of daily living (ADL), delirium, functional status, health-related quality of life (HRQoL), mobility, mortality (reported within four months of surgery as early mortality, and at 12 months since surgery), and unplanned return to theatre for treating a complication resulting directly or indirectly from the primary procedure (such as deep infection or non-union). We assessed the certainty of the evidence for these outcomes using GRADE.

MAIN RESULTS

We included 38 studies (32 RCTs, six quasi-RCTs) with 8585 participants with 8590 intracapsular fractures. The mean ages of participants in the studies ranged from 60 to 84 years; 73% were women, and 38% of fractures were undisplaced. We report here the findings of the four main comparisons, which were between different categories of implants. We downgraded the certainty of the outcomes for imprecision (when data were available from insufficient numbers of participants or the confidence interval (CI) was wide), study limitations (e.g. high or unclear risks of bias), and inconsistency (when we noted substantial levels of statistical heterogeneity). Smooth pins versus fixed angle plate (four studies, 1313 participants) We found very low-certainty evidence of little or no difference between the two implant types in independent mobility with no more than one walking stick (1 study, 112 participants), early mortality (1 study, 383 participants), mortality at 12 months (2 studies, 661 participants), and unplanned return to theatre (3 studies, 736 participants). No studies reported on ADL, delirium, functional status, or HRQoL. Screws versus fixed angle plates (11 studies, 2471 participants) We found low-certainty evidence of no clinically important differences between the two implant types in functional status using WOMAC (MD -3.18, 95% CI -6.35 to -0.01; 2 studies, 498 participants; range of scores from 0 to 96, lower values indicate better function), and HRQoL using EQ-5D (MD 0.03, 95% CI 0.00 to 0.06; 2 studies, 521 participants; range -0.654 (worst), 0 (dead), 1 (best)). We also found low-certainty evidence showing little or no difference between the two implant types in mortality at 12 months (RR 1.04, 95% CI 0.83 to 1.31; 7 studies, 1690 participants), and unplanned return to theatre (RR 1.10, 95% CI 0.95 to 1.26; 11 studies, 2321 participants). We found very low-certainty evidence of little or no difference between the two implant types in independent mobility (1 study, 70 participants), and early mortality (3 studies, 467 participants). No studies reported on ADL or delirium. Screws versus smooth pins (seven studies, 1119 participants) We found low-certainty evidence of no or little difference between the two implant types in mortality at 12 months (RR 1.07, 95% CI 0.85 to 1.35; 6 studies, 1005 participants; low-certainty evidence). We found very low-certainty evidence of little or no difference between the two implant types in early mortality (3 studies, 584 participants) and unplanned return to theatre (5 studies, 862 participants). No studies reported on ADL, delirium, functional status, HRQoL, or mobility. Screws or smooth pins versus fixed angle plates (15 studies, 3784 participants) In this comparison, we combined data from the first two comparison groups. We found low-certainty evidence of no or little difference between the two groups of implants in mortality at 12 months (RR 1.04, 95% CI.083 to 1.31; 7 studies, 1690 participants) and unplanned return to theatre (RR 1.02, 95% CI 0.88 to 1.18; 14 studies, 3057 participants). We found very low-certainty evidence of little or no difference between the two groups of implants in independent mobility (2 studies, 182 participants), and early mortality (4 studies, 850 participants). We found no additional evidence to support the findings for functional status or HRQoL as reported in 'Screws versus fixed angle plates'. No studies reported ADL or delirium.

AUTHORS' CONCLUSIONS

There is low-certainty evidence that there may be little or no difference between screws and fixed angle plates in functional status, HRQoL, mortality at 12 months, or unplanned return to theatre; and between screws and pins in mortality at 12 months. The limited and very low-certainty evidence for the outcomes for which data were available for the smooth pins versus fixed angle plates comparison, as well as the other outcomes for which data were available for the screws and fixed angle plates, and screws and pins comparisons means we have very little confidence in the estimates of effect for these outcomes. Additional RCTs would increase the certainty of the evidence. We encourage such studies to report outcomes consistent with the core outcome set for hip fracture, including long-term quality of life indicators such as ADL and mobility.

Treatment of femoral neck fractures: sliding hip screw or cannulated screws? A meta-analysis

Purpose

Femoral neck fractures are still unsolved problems nowadays; sliding hip screw (SHS) and cannulated compression screw (CCS) are the most commonly used devices. We evaluated the clinical outcomes and complications in the treatment of femoral neck fractures between SHS and CCS in this meta-analysis to find which is better.

Methods

We searched PubMed, Embase, Cochrane library up to 24 August 2020 and retrieved any studies comparing sliding hip screw and cannulated compression screw in treatment of femoral neck fractures; the main outcomes and complications were extracted from the studies which were included.

Results

Nine studies involving 1662 patients (828 patients in the SHS group and 834 patients in the CCS group) were included in this study. SHS had higher rate of avascular necrosis (RR = 1.30, 95% CI 1.08–1.56, p = 0.005), and CCS had higher rate of implant removal (RR = 0.63, 95% CI 0.43–0.93, p = 0.02). No significant statistical difference in non-union, implant failure, infection, replacement, mortality, orthopedic complications, non-orthopedic complications, and total revision between SHS and CCS group.

Conclusion

Both devices have their pros and cons; SHS had a higher rate of avascular necrosis, and CCS had a higher rate of implant removal rate. No significant statistical difference in non-union, implant failure, infection, replacement, mortality, orthopedic complications, non-orthopedic complications, and total revision between SHS and CCS group.

Efficacy of extracorporeal shock wave combined spinal core decompression for the treatment of patients with femoral head necrosis: A protocol for systematic review and meta-analysis

BACKGROUND

Previous studies have reported that extracorporeal shock wave (EPSW) combined spinal core decompression (SCD) has been used for the treatment of patients with femoral head necrosis (FHN) effectively. However, their results are still inconsistent. Therefore, this study will systematically assess the efficacy and safety of EPSW and SCD for the treatment of patients with FHN.

METHODS

This study will systematically search the following databases from inception through March 1, 2020: MEDLINE, Web of Science, Scopus, EMBASE, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, and China National Knowledge Infrastructure. All searches will be performed without language and publication date restrictions. This study will only include randomized controlled trials investigating the efficacy and safety of EPSW and SCD for the treatment of patients with FHN. Two authors will independently assess all literatures, extract data, and appraise risk of bias. Any confusion between 2 authors will be cleared up by a third author through discussion. RevMan 5.3 software will be utilized to analyze the data and to perform a meta-analysis if necessary.

RESULTS

This study will summarize up-to-date evidence and provide a detailed summary related to the efficacy and safety of EPSW and SCD for the treatment of patients with FHN.

CONCLUSION

This study may provide helpful evidence to determine whether or not EPSW combined SCD is effective and safety for the treatment of patients with FHN.

SYSTEMATIC REVIEW REGISTRATION

INPLASY202040092.

Failure Patterns of Femoral Neck Fracture Fixation in Young Patients

The primary purpose of this study was to describe the failure patterns of femoral neck fracture fixation in young patients. The secondary purpose was to determine if pattern of failure varies by type of implant. Adult patients (age range, 18-55 years) who experienced a "fixation failure" following internal fixation of a femoral neck fracture were identified from 5 level 1 trauma centers. Failure was defined by screw cutout, implant breakage, varus collapse (<120° neck-shaft angle), or severe fracture shortening (≥1 cm). When multiple complications were identified, mechanical failures were preferentially noted for the analysis. Failure patterns were compared between patients who received multiple cancellous screws and patients who received a sliding hip screw plus a derotation screw. Severe fracture shortening was the most common complication identified (61%). No differences in the incidence of severe shortening (P=.750) or implant breakage (P=1.000) were detected between the fixation groups. However, among the failures with a sliding hip screw plus a derotation screw construct, a greater portion were related to screw cutout (38% for a sliding hip screw plus a derotation screw vs 7% for screws, P=.019). Failures with multiple screws were associated with varus collapse (25% for screws vs 0% for a sliding hip screw plus a derotation screw, P=.037). Severe shortening was the most common fixation failure. Sliding hip screw plus derotation screw implants were associated with screw cutout. Multiple cancellous screw implants failed by varus collapse. Selecting a surgical implant based on its likely failure pattern may allow surgeons to minimize the severity of failure or the need for secondary conversion to hip arthroplasty. [Orthopedics. 2019; 42(4):e376-e380.].

Sliding hip screws versus cancellous screws for femoral neck fractures: a systematic review and meta-analysis

PURPOSE

Both sliding hip screws (SHS) and cancellous screws are used in the surgical management of intracapsular femoral neck fracture. However, there is paucity of information as to which is the superior treatment modality. We performed this systematic review and meta-analysis study to compare the clinical outcomes of SHS and cancellous screws for the treatment of femoral neck fractures in adult patients.

METHODS

We searched PubMed, Scopus, Web of Science, and Cochrane CENTRAL, up to December 2017. Randomized controlled trials (RCTs) directly comparing the clinical outcomes of SHS and cancellous screws for femoral neck fractures were retrieved with no language or publication year restrictions. Data retrieved included operative details, nonunion rate, avascular necrosis, reoperation, infection and mortality, hip pain, functional hip scores, and medical complications. These were pooled as risk ratio or mean difference (MD) with their corresponding 95% confidence interval (CI). Heterogeneity was assessed by Chi-square test.

RESULTS

Ten RCTs involving 1934 patients were included in the final analysis. The pooled estimate showed that the SHS group was associated with more intraoperative blood loss (MD = 110.01 ml, 95% CI [52.42, 167.60], p = 0.00002) than the cancellous screws. There was no significant difference in terms of operative time, postoperative hip function, nonunion, avascular necrosis, reoperation rate, infection, fracture healing, hip pain, medical complications, and mortality rate.

CONCLUSION

Based on our study, the cancellous screws group was associated with less intraoperative blood loss in comparison with the SHS group. No other significant differences were found between the two interventions.

Fixation using alternative implants for the treatment of hip fractures (FAITH-2): design and rationale for a pilot multi-centre 2 × 2 factorial randomized controlled trial in young femoral neck fracture patients

BACKGROUND

Femoral neck fractures in patients ≤ 60 years of age are often very different injuries compared to low-energy, hip fractures in elderly patients and are difficult to manage because of inherent problems associated with high-energy trauma mechanisms and increased functional demands for recovery. Internal fixation, with multiple cancellous screws or a sliding hip screw (SHS), is the most common treatment for this injury in young patients. However, there is no clinical consensus regarding which surgical technique is optimal. Additionally, there is compelling rationale to use vitamin D supplementation to nutritionally optimize bone healing in young patients. This pilot trial will determine feasibility and provide preliminary clinical data for a larger definitive trial.

METHODS

We will conduct a multicenter, concealed randomized controlled pilot study, using a 2 × 2 factorial design in 60 patients aged 18-60 years with a femoral neck fracture. Eligible patients will be randomized in equal proportions to one of four groups: 1) SHS and vitamin D supplementation (4000 international units (IU) daily dose) for 6 months, 2) cancellous screws and vitamin D supplementation (4000 IU daily dose) for 6 months, 3) SHS and placebo, and 4) cancellous screws and placebo. Participants will be followed for 12 months post-fracture. Feasibility outcomes include initiation of clinical sites, recruitment, follow-up, data quality, and protocol adherence. Clinical outcomes, for both the pilot and planned definitive trials, include a composite of patient-important outcomes (re-operation, femoral head osteonecrosis, severe femoral neck malunion, and nonunion), health-related quality of life and patient-reported function, fracture healing complications, and radiographic fracture healing. A priori success criteria have been established. If the pilot study is deemed successful, study participants will be included in the definitive trial and clinical outcomes for the pilot will not be analyzed. If the pilot study is not deemed successful, clinical outcome data will be analyzed.

DISCUSSION

Results of this study will inform the feasibility of a definitive trial. If clinical outcome data are analyzed, they will be disseminated through a publication and presentations.

TRIAL REGISTRATION

The FAITH-2 trial, described as a definitive trial, was registered at ClinicalTrials.gov (NCT01908751) prior to enrollment of the first participant.

Novel Treatment Options for the Surgical Management of Young Femoral Neck Fractures

In physiologically young patients with displaced femoral neck fractures, surgical treatment is aimed at achieving fracture union while preserving native hip anatomy and biomechanics. The intracapsular environment, tenuous vascular supply, and unfavorable hip biomechanics contribute to the high complication rates seen after osteosynthesis of these fractures. Conventional fixation methods for osteosynthesis of femoral neck fractures include multiple cancellous screws, fixed-angle dynamic implants, and fixed-angle length-stable constructs. Despite several biomechanical and clinical studies evaluating various surgical options, the optimal fixation construct to allow healing and prevent nonunion of displaced femoral neck fractures is not known. This article will review the clinical data regarding conventional fixation constructs and describe the technique and rationale behind 2 novel alternative treatment options for these challenging fractures. The surgical technique and clinical examples for constructs involving multiple cannulated screws/Pauwels screw augmented with a fibular strut graft, as well as a novel fixed-angle locking plate with controlled dynamic compression, are presented.

Anteromedial femoral neck plate with cannulated screws for the treatment of irreducible displaced femoral neck fracture in young patients: a preliminary study

BACKGROUNDS

Although most displaced femoral neck fractures of young patients can be repositioned successfully by closed reduction, there are still some can not repositioned successfully by this way and open reductions are required. This type of fracture was defined as irreducible displaced femoral neck fracture in this study. The purpose of this study was to introduce a new technique using anteromedial femoral neck plate with cannulated screws fixation by open reduction for the treatment of irreducible displaced femoral neck fractures in young patients.

METHODS

Totally 26 patients with irreducible displaced femoral neck fracture treated by this technique were retrospectively reviewed. This technique included three major steps: open reduction of femoral neck fracture was performed via the modified anterior approach of hip joint, anteromedial femoral neck plate was fixed to the femoral neck, and two cannulated compression screws were inserted in the femoral neck inside.

RESULTS

All patients were followed up with an average of 18months (range 12-30 months). Radiological and clinical outcomes were evaluated. The fracture union was achieved in 24 patients (92.3%) with an average duration of 4.5 months (range 3.8-10 months). Nonunion was not observed in all cases. Avascular necrosis of femoral head was identified in two patients (7.7%). Clinical outcomes of 24 hips with satisfactory union were evaluated by the Harris Hip Scores (HHS), excellent outcomes were achieved in 20 cases (HHS ≧ 90), fair outcomes in 3 cases (80 ≦ HHS < 90), and poor outcome in 1 case (HHS < 80).

CONCLUSIONS

Anteromedial femoral neck plate with cannulated screws fixation by open reduction is an alternative therapeutic method for the irreducible displaced femoral neck fracture in young patients, with low incidence of complications including nonunion and avascular necrosis.

Displaced femoral neck fractures in patients 60 years of age or younger: results of internal fixation with the dynamic locking blade plate

Aims

The objective of this study was to investigate bone healing after internal fixation of displaced femoral neck fractures (FNFs) with the Dynamic Locking Blade Plate (DLBP) in a young patient population treated by various orthopaedic (trauma) surgeons.

Patients and Methods

We present a multicentre prospective case series with a follow-up of one year. All patients aged ≤ 60 years with a displaced FNF treated with the DLBP between 1st August 2010 and December 2014 were included. Patients with pathological fractures, concomitant fractures of the lower limb, symptomatic arthritis, local infection or inflammation, inadequate local tissue coverage, or any mental or neuromuscular disorder were excluded. Primary outcome measure was failure in fracture healing due to nonunion, avascular necrosis, or implant failure requiring revision surgery.

Results

In total, 106 consecutive patients (mean age 52 years, range 23 to 60; 46% (49/106) female) were included. The failure rate was 14 of 106 patients (13.2%, 95% confidence interval (CI) 7.1 to 19.9). Avascular necrosis occurred in 11 patients (10.4%), nonunion in six (5.6%), and loss of fixation in two (1.9%).

Conclusion

The rate of fracture healing after DLBP fixation of displaced femoral neck fracture in young patients is promising and warrants further investigation by a randomized trial to compare the performance against other contemporary methods of fixation. Cite this article: Bone Joint J 2018;100-B:443–9.

The efficacy of rotational control designs in promoting torsional stability of hip fracture fixation

OBJECTIVES

Fractures of the proximal femur are a common clinical problem, and a number of orthopaedic devices are available for the treatment of such fractures. The objective of this study was to assess the rotational stability, a common failure predictor, of three different rotational control design philosophies: a screw, a helical blade and a deployable crucifix.

METHODS

Devices were compared in terms of the mechanical work (W) required to rotate the implant by 6° in a bone substitute material. The substitute material used was Sawbones polyurethane foam of three different densities (0.08 g/cm³, 0.16 g/cm³ and 0.24 g/cm³). Each torsion test comprised a steady ramp of 1°/minute up to an angular displacement of 10°.

RESULTS

The deployable crucifix design (X-Bolt), was more torsionally stable, compared to both the dynamic hip screw (DHS, p = 0.008) and helical blade (DHS Blade, p= 0.008) designs in bone substitute material representative of osteoporotic bone (0.16 g/cm³ polyurethane foam). In 0.08 g/cm³ density substrate, the crucifix design (X-Bolt) had a higher resistance to torsion than the screw (DHS, p = 0.008). There were no significant differences (p = 0.101) between the implants in 0.24 g/cm³ density bone substitute.

CONCLUSIONS

Our findings indicate that the clinical standard proximal fracture fixator design, the screw (DHS), was the least effective at resisting torsional load, and a novel crucifix design (X-Bolt), was the most effective design in resisting torsional load in bone substitute material with density representative of osteoporotic bone. At other densities the torsional stability was also higher for the X-Bolt, although not consistently significant by statistical analysis.Cite this article: J. D. Gosiewski, T. P. Holsgrove, H. S. Gill. The efficacy of rotational control designs in promoting torsional stability of hip fracture fixation. Bone Joint Res 2017;6:270-276. DOI: 10.1302/2046-3758.65.BJR-2017-0287.R1.

Fracture fixation in the operative management of hip fractures (FAITH): an international, multicentre, randomised controlled trial

BACKGROUND

Reoperation rates are high after surgery for hip fractures. We investigated the effect of a sliding hip screw versus cancellous screws on the risk of reoperation and other key outcomes.

METHODS

For this international, multicentre, allocation concealed randomised controlled trial, we enrolled patients aged 50 years or older with a low-energy hip fracture requiring fracture fixation from 81 clinical centres in eight countries. Patients were assigned by minimisation with a centralised computer system to receive a single large-diameter screw with a side-plate (sliding hip screw) or the present standard of care, multiple small-diameter cancellous screws. Surgeons and patients were not blinded but the data analyst, while doing the analyses, remained blinded to treatment groups. The primary outcome was hip reoperation within 24 months after initial surgery to promote fracture healing, relieve pain, treat infection, or improve function. Analyses followed the intention-to-treat principle. This study was registered with ClinicalTrials.gov, number NCT00761813.

FINDINGS

Between March 3, 2008, and March 31, 2014, we randomly assigned 1108 patients to receive a sliding hip screw (n=557) or cancellous screws (n=551). Reoperations within 24 months did not differ by type of surgical fixation in those included in the primary analysis: 107 (20%) of 542 patients in the sliding hip screw group versus 117 (22%) of 537 patients in the cancellous screws group (hazard ratio [HR] 0·83, 95% CI 0·63-1·09; p=0·18). Avascular necrosis was more common in the sliding hip screw group than in the cancellous screws group (50 patients [9%] vs 28 patients [5%]; HR 1·91, 1·06-3·44; p=0·0319). However, no significant difference was found between the number of medically related adverse events between groups (p=0·82; appendix); these events included pulmonary embolism (two patients [<1%] vs four [1%] patients; p=0·41) and sepsis (seven [1%] vs six [1%]; p=0·79).

INTERPRETATION

In terms of reoperation rates the sliding hip screw shows no advantage, but some groups of patients (smokers and those with displaced or base of neck fractures) might do better with a sliding hip screw than with cancellous screws.

FUNDING

National Institutes of Health, Canadian Institutes of Health Research, Stichting NutsOhra, Netherlands Organisation for Health Research and Development, Physicians' Services Incorporated.

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.

Dynamic hip screw fixation versus multiple screw fixation for intracapsular hip fracture

PURPOSE

To compare dynamic hip screw (DHS) fixation with multiple screw fixation for intracapsular hip fractures in terms of complications and conversion to hemiarthroplasty or total hip arthroplasty (THA).

METHODS

Records of 52 884 patients aged ≥50 years who underwent internal fixation using a dynamic hip screw (n=18 014, 34.1%) or multiple screws (n=34 870, 65.9%) for intracapsular femoral neck fracture from September 2007 to September 2013 were extracted from the hospital admission database that covers all admissions to the National Health Service hospitals in England using the ICD-10 and OPCS-4 codes. Gender, age, and Charlson comorbidity score of each patient were recorded, as were complications at specific time intervals and revision to hemiarthroplasty or THA at one and 4 years.

RESULTS

Compared with DHS fixation, multiple screw fixation resulted in shorter hospital stay (15 vs. 13 days, p<0.001) and lower rates of 30-day myocardial infarction (2% vs. 1.5%, p=0.022), 30-day lower respiratory tract infection (12.4% vs. 10.6%, p=0.001), 90-day mortality (10.4% vs. 8.6%, p=0.001), and avascular necrosis (0.1% vs. 0.06%, p=0.032), but a higher rate of conversion to hemiarthroplasty or THA at one or 4 years (all p<0.001).

CONCLUSION

Multiple screw fixation for intracapsular hip fracture was associated with a higher conversion rate to hemiarthroplasty or THA at one and 4 years, compared with DHS fixation.

Low failure rate by means of DLBP fixation of undisplaced femoral neck fractures

Background

This study evaluated the clinical results of a new implant in the internal fixation of undisplaced femoral neck fractures.

Method

Irrespective of their age, 149 patients with undisplaced (Garden I and II) femoral neck fractures were included in a prospective multicentre clinical cohort study and were treated by internal fixation by means of the Dynamic Locking Blade Plate (DLBP). The mean age was 69 years and the follow-up at least one year.

Results

The DLBP fixation resulted in 6 out of 149 failures caused by AVN (2x), non-union (2x), loss of fixation (3x) or combination of these.

Conclusion

The fixation of undisplaced femoral neck fractures by the DLBP resulted in a low failure rate of 4 %.

Timing of internal fixation of femoral neck fractures. A systematic review and meta-analysis of the final outcome

The aim of the present study was to evaluate the effect of timing of internal fixation of intracapsular fractures of the neck of femur on the development of late complications, particularly osteonecrosis of femoral head (ONFH) and non-union. We undertook a systematic review of the literature adhering to the PRISMA guidelines. There were 7 eligible reports for the final analysis. The methodological quality of component studies was assessed with the Coleman Methodology Score (CMS). Each included study was assigned a score independently by the two reviewers. The final score of each individual study constituted the average value of the scores given by the two reviewers. The agreement between the two assessors was tested with intraclass correlation coefficient (ICC). The CMS ranged from 37 to 64 within component studies (mean: 46.5, SD: 10.8, median: 41). The ICC was 0.94 (95% CI: 0.69-0.99), implying a nearly perfect agreement between the two assessors. Based on the available data regarding the timing of operative fixation of the femoral neck fractures, 4 discreet pairs of comparison groups could be created: (1) fractures fixed within 6h from injury versus fractures fixed after 6h from injury; (2) fractures fixed within 12h versus after 12h; (3) fractures fixed within 24h versus after 24h; and (4) fractures fixed within 6h versus after 24h. Outcome measures were analyzed within each one of the above pairs of treatment groups. The following subgroups analyses were a priori decided: (1) initial fracture displacement (displaced vs. undisplaced fractures); (2) fixation method (cannulated screws vs. sliding hip screw); (3) quality of reduction (anatomic vs non-anatomic reduction). This study failed to prove any essential association between timing of NOF fracture internal fixation and incidence of AVN. With respect to non-union though, it indicated that delay of internal fixation of more than 24h could increase substantially the odds of non-union.

Fixed angle devices versus multiple cancellous screws: what does the evidence tell us?

Complications, including nonunion and avascular necrosis, are relatively common after internal fixation of a femoral neck fracture. Young patients are particularly impacted by these complications as salvage options often result in a suboptimal functional result. The quality of reduction appears to be of primary importance; however, it is unknown whether the choice of internal fixation affects the incidence of complications. In this article, we present the rationale and evidence for available internal fixation options. Current evidence is insufficient to recommend an optimal method of internal fixation, and this review demonstrates the need for high-quality randomised, controlled trials to study this problem.

Management of young femoral neck fractures: is there a consensus?

BACKGROUND

Femoral neck fractures in young adults (ages <60) are high-energy injuries that are associated with major fracture healing complications such as avascular necrosis, nonunion, and significant shortening. Historically, evidence from small trials has suggested multiple cannulated screws were the optimal implant; however, newer studies and implant designs warrant reevaluation of screws as the gold standard among surgeons. In addition, controversies surrounding reduction technique and urgency of surgical fixation have been previously identified. We aimed to survey surgeon treatment preferences for these challenging fractures.

METHODS

A 17-item survey was developed and tested for validity and reliability prior to administration. The questionnaire characterised surgeon demographics, treatment preferences for displaced and undisplaced fractures, and controversies for future clinical trials. The target population consisted of surgeons from the Canadian Orthopaedic Association, the Orthopaedic Trauma Association, and attendees at an international fracture course.

RESULTS

540 surgeons completed the survey, exceeding our sample size requirement. There was a similar proportion of respondents from academic and community hospitals. Most surgeons (61%) treat 1-5 young adult femoral neck fractures per year. For undisplaced fractures, 78% of respondents prefer to use multiple cannulated screws. For displaced fractures, equal preference for multiple screws (46%) and the sliding hip screw (SHS, 49%) was reported. The majority of surgeons perform an open reduction in less than 25% of cases, and the time to fixation was typically between 8 and 24h.

CONCLUSIONS

Multiple cannulated screws remain the preferred treatment for most surgeons treating undisplaced fractures; however, there is an equal divide in preference between multiple screws and the SHS for displaced fractures. This increased preference for the SHS contradicts previous survey and small trial data recommending multiple screws for all fracture patterns. The lack of surgeon consensus and the high rates of fracture complications associated with fixation of young femoral neck fractures supports the need for definitive clinical trials to optimise patient important outcomes.

Avascular necrosis of the femoral head following trochanteric fractures in adults: a systematic review

INTRODUCTION

Avascular necrosis of the femoral head (ANFH) following trochanteric fractures (TFx) is infrequent. The causal relationship between ANFH and TFx remains controversial. Although several major risk factors for ANFH have been proposed, most of them remain under discussion. In this study we undertook a systematic review of the literature to investigate the incidence of AVN, risk factors and outcomes following Tfx fixation.

MATERIALS AND METHODS

A comprehensive review of the literature was undertaken using the PRISMA guidelines with no language restriction. Case reports of ANFH and series of TFx with or without cases of ANFH published between inception of journals to December 2013 were eligible for inclusion. Relevant information was divided in two sections. Part I: included the analysis of detailed case reports of ANFH, either published isolated or included in series of TFx, with the objective of establishing potential risk factors, clinical and radiological presentation, time to development, treatment and outcome of this complication. Part II: analyzed series of TFx, which included cases of ANFH with or without details of aetiology, treatment modalities and outcomes, with the objective of assessing the incidence of ANFH in TFx.

RESULTS

Overall 80 articles with 192 cases of ANFH after TFx met the inclusion criteria. The most probable developmental pathway appears to be a disruption of the extra osseous arterial blood supply to the femoral head. Suggested risk factors included high-energy trauma with fracture comminution and displacement, and an atypical course of the fracture line, more proximal, at the base of the neck. Most cases were diagnosed within the first two years after fracture. The clinical and radiological features appear to be similar to those of idiopathic avascular necrosis of the femoral head. The incidence of AVFH with a minimum of 1-year follow-up was calculated 0.95%, and with a minimum 2-year follow-up it was 1.37%. Total hip replacement was the mainstay of treatment.

CONCLUSION

The incidence of AVFH after Tfx fixation is small 1.37% within the first 2 years of injury. Risk factors for the development of this complication are related to the severity of trauma, fragment geometry and fracture displacement. Optimum surgery of these fractures cannot guarantee prevention of ANFH.

A CURRENT REVIEW ON THE BIOLOGY AND TREATMENT OF ARTICULAR CARTILAGE DEFECTS (PART I & PART II)

Osteochondral injury occurs predominantly in physically active young adult males. Injury to the articular cartilage and/or subchondral bone may not only cause acute joint disease resulting in osseous intracapsular (synovitis) or extracapsular pain, but may also act to spawn arthritic conditions in later life. Since the 18th century, such injury has proven difficult to treat clinically, and much therapy has been essentially palliative. Past treatments such as abrasion arthroplasty, drilling, microfracture and arthroscopic lavage have been useful in removing articular debris and promoting the formation of the fibrin clot used in most native repair mechanisms. However, the limitation of these techniques is their inability to restore the damaged cartilage and subchondral bone to their normal tissue architecture. Recent developments in tissue engineering have concentrated on the utilization of autologous chondrocyte implantation, biomaterials and growth factors to promote the regeneration of biomechanically superior hyaline articular cartilage. This paper reviews the etiology, repair biology and therapeutic techniques of cartilage and/or osteochondral injury over the previous decades, and attempts to provide insight into interesting new research directions which offer much potential for improved treatment of these troublesome lesions.

Evidence summary: systematic review of surgical treatments for geriatric hip fractures

BACKGROUND

There is a growing body of literature on surgical treatments for elderly patients with a hip fracture and the effects of various surgical procedures on complications and postoperative outcomes. No single review has previously summarized the literature on the effects of surgical procedures on outcomes after treatment across all types of hip fractures. We conducted a comprehensive systematic literature review to organize the clinical evidence for patient-centered outcomes across all types of geriatric hip fractures.

METHODS

We searched MEDLINE, the Cochrane Database of Systematic Reviews, Scirus, and ClinicalTrials.gov for randomized clinical trials and observational studies published between 1985 and 2008. We also manually searched reference lists from relevant systematic reviews.

RESULTS

We found eighty-four [corrected] articles representing seventy-four [corrected] unique, randomized, controlled trials, including thirty-three [corrected] on femoral neck fractures, forty on intertrochanteric fractures, and one on subtrochanteric fractures. Nine observational studies addressed the link between patient characteristics and outcome variables by fracture type. Age, sex, prefracture functioning, and cognitive impairment are related to mortality and functional outcomes. Fracture type does not appear to be independently related to patient outcomes. Mortality, pain, function, and quality of life did not differ by surgical implant class, or by implants within a class. Neither the randomized controlled trials nor the observational literature include the full complement of potential covariates that can impact treatment outcomes after treatment.

CONCLUSIONS

The broader questions about the relationship of patient factors, fracture type, and specific treatments to the outcomes of mortality, functional status, and quality of life cannot be addressed with the existing literature. Research should include comprehensive conceptual models that capture complete sets of important independent variables. Studies of musculoskeletal outcomes, including hip fracture, require well-defined patient groups and consistent use of validated outcome measures.

The dynamic locking blade plate, a new implant for intracapsular hip fractures: biomechanical comparison with the sliding hip screw and Twin Hook

Internal fixation of intracapsular hip fractures results in a high failure rate with non-union and avascular necrosis being the two most important complications. In order to prevent these possible complications treatment should consist of an anatomical reduction and stable fixation by insertion of a low volume, dynamic implant, providing angular and rotational stability to the femoral head. According to these principles a new implant, the dynamic locking blade plate (DLBP) was designed for the fixation of intracapsular hip fractures. We performed a biomechanical analysis in synthetic bone to compare the rotational stability and cut out resistance of the DLBP with a conventional sliding hip screw (SHS) and the more recently developed Twin Hook. The rotational stability of the DLBP proved to be three times higher than the rotational stability of a SHS and two times higher than the Twin Hook. There was no major difference in cut out resistance between the different implants. The design of the DLBP and possible advantages with regard to the healing of an intracapsular hip fracture are discussed.

Surgical management of fractured neck of femur

The fractured neck of femur is the classically described fracture in osteoporotic elderly patients. Further, the fracture has a strong predominance in post-menopausal women and, although relatively uncommon in both children and young adults, where present in this age group it is usually the result of significant trauma. In elderly patients, with an already weakened bone, even minimal trauma may be sufficient to cause fracture and as such a fractured neck of femur is often referred to as a fragility fracture.

Minimally displaced intra-capsular femoral neck fractures in the elderly--comparison of multiple threaded pins and sliding compression screws surgical techniques

PURPOSE

To determine the outcome of treatment for minimally displaced femoral neck fractures using multiple threaded pins versus sliding compression screws for internal fixation.

METHODS

The medical records of 62 consecutive elderly patients with minimally displaced intra-capsular femoral neck fractures who underwent internal fixation of the fracture (37 with multiple threaded pins, and 25 with sliding compression screws) were reviewed. Clinical and radiological assessment of fracture healing at follow-up visits were noted.

RESULTS

In the 55 patients seen for follow-up at 3 months, 21.9% (n=7) of those treated by pinning demonstrated non-union of the fracture, and 0% of fractures treated with sliding compression screws (p=0.02). 46 patients were seen for follow-up at one year, with 10% (n=2) of those treated with sliding compression screws found to have osteonecrosis of the femoral head. The 2 fractures in the group treated by pinning demonstrating non-union at 3 months failed to unite by one year (p=0.11). 34 patients were seen for follow-up for at least 2 years, with no additional complications noted.

CONCLUSION

Using sliding compression screws to treat minimally displaced femoral neck fractures can achieve a higher union rate than using pinning. The reason may be the better stability in the osteoporotic bone. However, osteonecrosis of the femoral head may occur with use of sliding compression screws because of greater intramedullary vascular damage as a result of wider reaming.

Necrosis of the femoral head after fixation of trochanteric fractures with Gamma Locking Nail. A cause of late mechanical failure

Cut-out of the lag screw after fixation of trochanteric fractures with intramedullary devices like the Gamma Locking Nail is a well documented cause of late mechanical failure. Avascular necrosis of the femoral head after trochanteric fractures is an uncommon complication and several causes have been described. As far as we know, the relation of the mechanical failure of fracture fixation and avascular necrosis of the femoral head in trochanteric fractures has never been described. We present a study of six consecutive patients who underwent arthroplasty after cut-out of the lag screw fixation of a trochanteric fracture with Gamma Locking Nail. All six femoral heads were studied histologically and a clinical retrospective study was also performed. In all cases, we found homogeneous avascular necrosis of the femoral head; in all but one, revascularisation was present in every area examined. We suggest that after fixation of these trochanteric fractures with the Gamma Locking Nail, there is a transitory ischaemia, if the revascularisation is not enough to provide a strong support for the lag screw, it may result in late mechanical failure in these fractures.

Fractures of the proximal part of the femur in patients under 50 years of age

We present a retrospective study of the epidemiology and the results of treatment of fractures of the proximal femur in 74 patients aged 50 or under. Cervical fractures comprised 17% of the 74 fractures and were equally caused by high and low energy trauma. Trochanteric and subtrochanteric fractures comprised 83% of the total and were mainly caused by high-energy trauma. The rate of complications was 25% for the cervical fractures (two avascular necroses and one non-union) and was attributed to a valgus malalignment and to the use of bulky implants. Similarly the rate of complications was 22.5% for the trochanteric and subtrochanteric fractures (mal-union and displacement into varus) and was attributed to early collapse of the fracture and the inability of the implant to withstand the strain before osseous union. Furthermore, intramedullary fixation of subtrochanteric fractures should be preferred to the sliding screw and side plate. In conclusion, we believe that proximal femoral fractures in young patients require great attention to the correct reduction and the appropriate choice of implant, in order to minimize the chances of the development of serious complications.

Internal fixation implants for intracapsular proximal femoral fractures in adults

BACKGROUND

Numerous different implants with screws, pins and side plates have been used for the internal fixation of intracapsular hip fractures.

OBJECTIVES

To determine from randomised trials which implant is superior for the internal fixation of intracapsular proximal femoral fractures.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group specialised register. The date of the most recent search was December 2000.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing different implants for the internal fixation of intracapsular hip fractures in adults.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality, by use of a ten item scale, and extracted data. Additional information was sought from trialists. After grouping by implant type, comparable groups of trials were subgrouped and where appropriate, data were pooled using the fixed effects model.

MAIN RESULTS

Twenty-seven studies involving 5269 participants (5274 fractures) were included in the study. Considerable variation in the quality of methodology between studies was found and biases due to familiarity with some of the implants were noted. None of the implants tested were found to be significantly superior for any of the outcome measures related to fracture healing complications or mortality. The sliding hip screw was found to take longer to insert and to have an increased operative blood loss compared with multiple screws or pins.

REVIEWER'S CONCLUSIONS

No clear conclusions can be made on the choice of implant for internal fixation of intracapsular fractures from the available evidence within randomised trials.

Avascular necrosis of the femoral head after intertrochanteric fractures

OBJECTIVE

To determine factors that may influence the appearance of avascular necrosis after intertrochanteric fractures.

DESIGN

Retrospective.

SETTING

University hospital.

PATIENTS

Twelve patients between the ages of fifty-nine and eighty-eight who had developed avascular necrosis of the femoral head after treatment of an intertrochanteric femur fracture at our institution between 1976 and 1995. Fractures were classified according to Kyle and Gustilo. There were three Type I, two Type II, six Type III, and one Type IV fractures.

MAIN OUTCOME MEASURES

Risk factors for osteonecrosis, fracture pattern, surgical influence, location of the nail within the femoral head, and valgus malalignment.

RESULTS

All fractures healed. Five patients had risk factors for osteonecrosis. Intertrochanteric fractures with a proximal fracture line appeared in five patients. The nail tip was situated in every quadrant of the femoral head. Valgus malalignment occurred in three cases.

CONCLUSIONS

Avascular necrosis of the femoral head is an uncommon complication after intertrochanteric fractures. The pathogenesis is unknown, but in patients developing pain who have had intertrochanteric fractures, osteonecrosis should be included in the differential diagnosis, especially in cases with risk factors for osteonecrosis or a proximal intertrochanteric fracture line that perhaps disrupts the vascular anastomotic ring at the base of the femoral neck.

Avascular necrosis of the femoral head after intertrochanteric fractures

OBJECTIVE

To determine factors that may influence the appearance of avascular necrosis after intertrochanteric fractures.

DESIGN

Retrospective.

SETTING

University hospital.

PATIENTS

Twelve patients between the ages of fifty-nine and eighty-eight who had developed avascular necrosis of the femoral head after treatment of an intertrochanteric femur fracture at our institution between 1976 and 1995. Fractures were classified according to Kyle and Gustilo. There were three Type I, two Type II, six Type III, and one Type IV fractures.

MAIN OUTCOME MEASURES

Risk factors for osteonecrosis, fracture pattern, surgical influence, location of the nail within the femoral head, and valgus malalignment.

RESULTS

All fractures healed. Five patients had risk factors for osteonecrosis. Intertrochanteric fractures with a proximal fracture line appeared in five patients. The nail tip was situated in every quadrant of the femoral head. Valgus malalignment occurred in three cases.

CONCLUSIONS

Avascular necrosis of the femoral head is an uncommon complication after intertrochanteric fractures. The pathogenesis is unknown, but in patients developing pain who have had intertrochanteric fractures, osteonecrosis should be included in the differential diagnosis, especially in cases with risk factors for osteonecrosis or a proximal intertrochanteric fracture line that perhaps disrupts the vascular anastomotic ring at the base of the femoral neck.

Unstable femoral neck fractures in young adults: treatment with the AO 130-degree blade plate

OBJECTIVE

To evaluate the clinical outcome of the treatment of unstable femoral neck fractures using the AO 130-degree blade plate.

DESIGN

Between 1980 and 1994, thirty-four consecutive patients younger than age fifty years with an unstable intracapsular femoral neck fracture (Garden Types III-IV) were treated with internal fixation.

SETTING

University Hospital Gasthuisberg, Leuven, Belgium.

INTERVENTION

The AO 130-degree blade plate with an antirotation, 6.5-millimeter, partially threaded cancellous lag screw was used.

RESULTS

Nineteen (63.3 percent) patients had an excellent result, seven (23.3 percent) had a good result, three (10 percent) had a fair result, and one (3.3 percent) had a poor result. Delayed union was observed in one case, and avascular necrosis was observed in two cases. Two implants perforated the subchondral bone.

CONCLUSION

Stable fixation with the AO 130-degree blade plate avoids damage to the adjacent blood supply to the femoral head and appears to guarantee a good final outcome of unstable intracapsular femoral neck fractures in young adults.

Percutaneous osteosynthesis with two screws in treating femoral neck fractures

In a consecutive, retrospective study, 182 patients were followed 1 year after surgical treatment of a fractured femoral neck. The patients were admitted on alternate days to the neighboring departments of orthopedic surgery O and phi, respectively. In Department O, the patients were submitted to sliding screw-plate (SSP) osteosynthesis, while patients in Department phi were treated with two percutaneously introduced screws. Our results showed that double-screw osteosynthesis can be performed significantly quicker and with less blood loss than application of SSP. Healing of the fractures in the two groups did not differ significantly, nor did the cumulative rate of failure or the frequency of secondary surgical procedures. We find that, judged from these parameters, percutaneously introduced double-screw osteosynthesis is at least as effective as SSP osteosynthesis.

Outcomes after displaced fractures of the femoral neck. A meta-analysis of one hundred and six published reports

Methods of meta-analysis, a technique for the combination of data from multiple sources, were applied to analyze 106 reports of the treatment of displaced fractures of the femoral neck. Two years or less after primary internal fixation of a displaced fracture of the femoral neck, a non-union had developed in 33 per cent of the patients and avascular necrosis, in 16 per cent. The rate of performance of a second operation within two years ranged from 20 to 36 per cent after internal fixation and from 6 to 18 per cent after hemiarthroplasty (relative risk, 2.6; 95 per cent confidence interval, 1.4 to 4.6). Conversion to an arthroplasty was the most common reoperation after internal fixation and accounted for about two-thirds of these procedures. The remaining one-third of the reoperations were for removal of the implant or revision of the internal fixation. For the patients who had had a hemiarthroplasty, the most common reoperations were conversion to a total hip replacement, removal or revision of the prosthesis, and débridement of the wound. Although we observed an increase in the rate of mortality at thirty days after primary hemiarthroplasty compared with that after primary internal fixation, the difference was not significant (p = 0.22) and did not persist beyond three months. The absolute difference in perioperative mortality between the two groups was small. An anterior operative approach for arthroplasty consistently was associated with a lower rate of mortality at two months than was a posterior approach. Some reports showed promising results after total hip replacement for displaced fractures of the femoral neck; however, randomized clinical trials are still needed to establish the value of this treatment.

Implant/bone constructs in femoral neck osteotomy. An autopsy study

Previous studies have suggested that three rather than two screws may give better results in the treatment of femoral neck fractures. In the present study, the strength of various screw/bone constructs in femoral neck osteotomy was analyzed. Transverse osteotomies on 65 cadaver femora were fixed with two or three screws of two types: one with a shank diameter of 6 mm and thread diameter of 8 mm, and a prototype screw with equal shank and thread diameter of 7 mm. The femoral heads were subjected to static and cyclic loads in the one-legged stance position. Single-energy quantitative computed tomography measurements were correlated to load. The two experimental models resulted in different patterns of failure of the bone/implant constructs, otherwise the results were similar. Three of the prototype screws gave the strongest construct, while two of the other screw type were stronger than three. The explanations for the diverging properties of the different bone/implant constructs may be that large threads destroy too much of the bone trabeculae, and that screw threads larger than the shank may destroy the drill canal and produce an unstable situation compared with screws with equal shank and thread diameter.

Internal fixation of femoral neck fractures. Dynamic Hip and Gouffon screws compared in 73 patients

A prospective, randomized study comparing the Dynamic Hip screws and the Gouffon screws in the treatment of femoral neck fractures was terminated before the planned number of patients had been admitted, owing to a preponderance of early failure of the Gouffon screws (P 0.014); thus only 73 patients entered the study. After three years' follow-up, 25/38 Gouffon screws and 12/35 Dynamic Hip screws had failed. Six patients treated with Gouffon screws and 14 treated with Dynamic Hip screws had died. The outcome still favoured the use of Dynamic Hip screws (P 0.02).

Stability of femoral neck osteosynthesis. Comparison of fixation methods in cadavers

Fixation of vertical femoral neck osteotomies in 50 cadavers was performed with either von Bahr screws or a sliding hip compression screw. One specimen from each pair of femora was used for the osteotomy, the other serving as an intact control. At 0.05 r of torsion the load-deformation test showed that three von Bahr screws provided the strongest fixation, and this was confirmed by the the ultimate torsional moment test. Regardless of positioning, even two von Bahr screws were stronger than the sliding compression screw with or without an additional lag screw. The results indicate that the best torsional stability in femoral neck fractures can be obtained with three 5.5-mm screws.

Alternatives in the treatment of ipsilateral fractures of the hip and femur

Eight cases of ipsilateral femoral neck and shaft fractures were reviewed. The diagnosis of the femoral neck fracture was delayed in two cases. Seven of the femoral shaft fractures were comminuted. In six cases, both fractures were treated with rigid internal fixation. A combination of traction and internal fixation was used in two cases. Two cases of avascular necrosis of the femoral head were observed. The fracture reduction was insufficient in both cases and the diagnosis of femoral neck fracture was delayed in one case. A radiograph of the pelvis is mandatory in high-velocity trauma victims. Ipsilateral fractures of the femoral neck and shaft should be stabilized by internal fixation as early as possible. Intramedullary locked nailing seems to be an attractive alternative in the treatment of the comminuted femoral shaft fracture.

Early loss of fixation of femoral neck fractures. Comparison of three devices in 244 cases

In successive series of displaced subcapital femoral neck fractures in the elderly, we operated on 75 cases with three Gouffon screws, 94 with three Mecron screws, and 75 with two von Bahr screws. Redisplacement within 3 months occurred in 20 Gouffon cases, 11 Mecron cases, and 12 von Bahr cases. Poor reduction contributed to the failures in all the groups. Although the reduction results in the three groups were similar, the Mecron group had better fixation and better social recovery than the Gouffon group. We concluded that, in addition to good reduction of the fracture, solid screws also contributed to the stability of the bone-implant construct.

Fixation of displaced femoral neck fractures. A comparison between sliding screw plate and four cancellous bone screws

In a prospective, randomized trial, 104 consecutive patients with displaced femoral neck fractures were allocated either to fixation with a sliding screw plate or 4 ASIF cancellous bone screws. The patients were reexamined at fixed intervals to determine the time of union. The 2-year-cumulated rate of union was 64 per cent in the plate group and 84 per cent in the screw group.