Comparative analysis of treatment of basicervical femur fractures in young adults with CCS, DHS, and PFN

Treatment of non-displaced intracapsular femoral neck fractures with dynamic hip and cannulated screws resulting in avascular necrosis: A comparative study of complications

OBJECTIVES

To compare the complications associated with cannulated hip screws (CHS) and dynamic hip screws (DHS) techniques.

METHODS

In this multicenter retrospective chart study, we reviewed the records and data of all patients operated upon by DHS or CHS for treatment of Garden type I and type II intracapsular non-displaced femoral neck fracture from January 2017 to December 2022. Patients with incomplete files or follow-ups of less than one year were excluded from the study.

RESULTS

The study enrolled 85 patients, 35 males, and 50 females, with a mean age of 72±5.4 for males and 70.6±7.6 for females. A total of 44 patients were operated upon with DHS, and 41 patients with CHS. The mortality rate of DHS was 15.9% and was 17.1% in the CHS group (p>0.05). Non-union was recorded in 4.5% of the DHS group and 4.9% of CHS patients (p>0.05). Avascular necrosis (AVN) was significantly higher in DHS (9.1%) than in CHS (4.9%, p<0.05). A revision was required in 15.9% of DHS patients and 14.6% of CHS patients (p>0.05).

CONCLUSION

This study found that DHS was superior to CHS in AVN rate. However, there was no significant difference between both methods regarding mortality, revision, and non-union.

Primary Hemiarthroplasty for the Treatment of Basicervical Femoral Neck Fractures

Purpose

Basicervical femoral neck fractures are uncommon injuries that occur at the extracapsular base of the femoral neck at its transition with the intertrochanteric line. Controversy remains in the orthopedic literature as to the optimal method of treatment for this fracture type given the inherent instability and greater rate of implant failure with traditional fixation constructs. The purpose of this study is to quantify the incidence and preferred treatment methods of basicervical hip fractures at a single, regional, Level 1 trauma center and to identify differences in postoperative complications between treatment options.

Methods

The present study is a retrospective case series from a single regional health network, including 316 patients with hip fractures. Basicervical femoral neck fractures were identified. Reoperation rates within 90 days, implant failures or nonunions, postoperative ambulation distances and range of motion, and discharge dispositions were compared across patients grouped by surgical treatment with either cephalomedullary nail, sliding hip screw, or hemiarthroplasty (HA).

Results

Basicervical femoral neck fractures represented 6.6% of this study population. The cephalomedullary nail group demonstrated rates of implant failure and return to the operating room within 90 days of 40% (4/10) and 20% (2/10), respectively. No patients who underwent hemiarthroplasty experienced a failure of fixation or return to the operating room.

Conclusions

This study suggests a much lower rate of fixation failure or need for reoperation with hemiarthroplasty treatment compared to cephalomedullary nail construct for basicervical femoral neck fractures and may be an underutilized treatment method for this fracture type. The promising results seen with this case series should encourage further investigation into HA as a primary treatment for these uncommon, yet challenging, fractures.

Comparison of hip structure analysis and grip strength between femoral neck and basicervical fractures

Background

The purpose of this study was to analyze differences in geometrical properties of the proximal femur and predict the occurrence of basicervical fractures through a comparative study of femoral neck and basicervical fractures in patients undergoing hip structural analysis (HSA).

Methods

All patients with hip fractures who were at least 65 years old and admitted to our hospital between March 2017 and December 2019 were eligible for this study. During the study period, 149 femur neck fractures (FNF) and basicervical fractures (intertrochanteric fractures of A31.2) were included in this study. Fifty-nine patients were included in the final analysis. Factors considered to be important confounders affecting the occurrence of basicervical hip fractures were chosen for propensity-score analysis. A logistic model with basicervical hip fracture as the outcome and age, sex, weight, spinal T-score, hip T-score, and vitamin D levels as confounders was used to estimate the propensity score.

Results

The cross-sectional moment of inertia (CSMI) of the intertrochanter was significantly lower in patients with basicervical hip fracture (HF) than in patients with FNF (p = 0.045). However, there was no significant differences in any other HSA variable between the two groups. Receiver operating characteristic (ROC) analysis showed that cutoff point for HSA was 100 for hip axis length (HAL) (AUC = 0.659, p < 0.001) and 5.712 for CSMI of the intertrochanter (AUC = 0.676, p < 0.001). ROC analysis showed that cutoff points of HAL, CSMI of intertrochanter, and handgrip strength were 104.8, 8.75, and 16.9, respectively (AUC = 0.726, p < 0.001).

Conclusions

Proximal femoral geometric analysis using HSA is a useful method for predicting the type of hip fracture. Additionally, a lower CSMI, a shorter HAL, and a lower grip strength are major predictors of basicervical fractures.

[Effectiveness of proximal femoral nail anti-rotation for high plane intertrochanteric femur fractures]

Objective

To evaluate the effectiveness of proximal femoral nail anti-rotation (PFNA) in treatment of high plane intertrochanteric femur fractures.

Methods

A retrospective analysis was performed on 33 patients who underwent closed reduction and PFNA fixation for high plane intertrochanteric femur fracture between January 2016 and June 2019. There were 12 males and 21 females with an average age of 75.1 years (mean, 47-89 years). The fractures were caused by falling from height in 21 cases, by traffic accident in 7 cases, and by other injuries in 5 cases. Fractures were classified as type A in 14 cases and type B in 19 cases according to self-defined fracture classification criteria; and as type 31-A1.2 in 14 cases and as type 31-A2.2 in 19 cases according to AO/Orthopedic Trauma Association (AO/OTA) classification criteria. The time from injury to operation was 2-5 days (mean, 2.7 days). The operation time, intraoperative blood loss, hospital stay, fracture reduction quality, fracture healing time, internal fixation failure, and Parker-Palmer score were recorded.

Results

The operation time was 40-75 minutes (mean, 55 minutes). The intraoperative blood loss was 50-150 mL (mean, 64 mL). The hospital stay was 5-15 days (mean, 8.7 days). All incisions healed by first intention. Twenty-eight patients were followed up 12-18 months with an average of 13.6 months. The fracture reduction quality was rated as excellent in 9 cases (32.1%), good in 17 cases (60.7%), and poor in 2 cases (7.1%) by Chang's criteria. Parker-Palmer score was 6-9 (mean, 7.9) at last follow-up.

Conclusion

High plane intertrochanteric femur fracture is a special type of intertrochanteric fracture, which can be diagnosed by imaging examination. PFNA fixation can achieve satisfactory results and prevent the occurrence of internal fixation failure effectively.

Intramedullary Nail Breakage and Mechanical Displacement in Patients with Proximal Femoral Fractures: A Commercial and Medicare Supplemental Claims Database Analysis

Objective

This study evaluated the rates and patterns of intramedullary nail (IMN) breakage and mechanical displacement for proximal femur fractures and the factors associated with their occurrence.

Patients and Methods

Patients with subtrochanteric, intertrochanteric, or basicervical femoral neck fractures treated with IMN from 2016 to 2019 were identified from commercial and Medicare supplemental claims databases and were followed for up to two years. Kaplan–Meier analysis estimated the cumulative incidence of and patterns of breakage/mechanical displacement. Multivariable Cox regression models evaluated the factors associated with breakage/mechanical displacement.

Results

A total of 11,128 patients had IMN fixation for subtrochanteric, intertrochanteric, or basicervical femoral neck fractures: (mean SD) age 75.6 (16.4) years, 66.2% female, 74.3% Medicare supplemental vs 26.7% commercial insurance. Comorbidities included hypertension (62.9%), osteoporosis (27.3%), cardiac arrhythmia (23.1%), diabetes (30.7%), and chronic pulmonary disease (16.3%). Most fractures were closed (97.2%), intertrochanteric or basicervical femoral neck (80.1%), and not pathological (91.0%). The cumulative incidence of nail breakage over two years was 0.66% overall, 1.44% for combination fractures, 1.16% for subtrochanteric fractures, and 0.49% for intertrochanteric or basicervical fractures. The cumulative incidence of mechanical displacement was 0.37% overall, 0.43% for subtrochanteric fractures, 0.42% for combination fractures, and 0.36% for intertrochanteric or basicervical femoral neck fractures. Half of the breakages occurred within five months after surgery and half of the mechanical displacements occurred within 75 days. Age 50–64 (vs 75+) and subtrochanteric or pathological fracture were more commonly associated with nail breakage. Complicated hypertension was more commonly associated with mechanical displacement.

Conclusion

The incidence of IMN breakage and mechanical displacement in US commercial and Medicare supplemental patients with proximal femur fractures from 2016 to 2019 was low (0.66% and 0.37%, respectively up to two years). Age 50–64 (vs 75+) and subtrochanteric or pathological fracture were more commonly associated with breakage. Complicated hypertension was associated with mechanical displacement.

Dynamic hip screws versus cannulated screws for femoral neck fractures: a systematic review and meta-analysis

OBJECTIVE

Dynamic hip screw (DHS) and cannulated screws (CS) are widely used for femoral neck fractures. However, there is no definite result as to which surgical method bring less complications. We performed this study to compare the complication (mortality, non-union, avascular necrosis (AVN), and revision) of DHS and CS for the treatment of femoral neck fractures patients.

METHODS

We searched Pubmed, Ovid, Cochrane Central Register of Controlled Trials, and other relevant studies related the comparison of DHS versus CS for femoral neck fractures from inception to Jan 7, 2020. The quality of the included randomized controlled trials (RCTs) and retrospective studies were assessed using the Cochrane Collaboration tool and Newcastle-Ottawa (NOS), respectively. The meta-analysis was performed by the RevMan 5.2 software.

RESULTS

Nine RCTs and seven retrospective cohort studies were included for meta-analysis. CS was found to be superior to DHS with respect to AVN rate (OR 1.47; 95% CI 1.08-1.99; p = 0.01, I² = 0%). There were no significant between-group differences with respect to mortality, non-union, and revision (p > 0.05).

CONCLUSION

DHS and CS have similar complication including mortality, revision rate, and non-union, but CS has superior to DHS on ANV. However, further studies are required to provide more robust evidence owing to some limitations.