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Collinge CA, Giga K, Roser T, Lebus GF, Beltran MJ, Crist B, Sems SA, Gardner MJ, Sagi HC, Archdeacon MT, Mir HR, Rodriguez-Buitrago A, Mitchell P, Tornetta P. Treatment Failure After Repair of Displaced Femoral Neck Fractures in Patients Compared by "Decade of Life": An Analysis of 565 Cases in Adults Less Than 60 years of Age. J Orthop Trauma 2024; 38:418-425. [PMID: 39007657 DOI: 10.1097/bot.0000000000002840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 07/16/2024]
Abstract
OBJECTIVES To study the results of displaced femoral neck fractures (FNFs) in adults less than 60 years of age by comparing patients, injury, treatment, and the characteristics of treatment failure specifically according to patients' age at injury, that is, by their "decade of life" [ie, "under 30" (29 years and younger), "the 30s" (30-39 years), "the 40s" (40-49 years), and "the 50s" (50-59 years)]. METHODS DESIGN Multicenter retrospective comparative cohort series. SETTING Twenty-six North American Level 1 Trauma Centers. PATIENT SELECTION CRITERIA Skeletally mature patients aged 18-59 years with operative repair of displaced FNFs. OUTCOME MEASURES AND COMPARISONS Main outcome measures were treatment failures (fixation failure and/or nonunion, osteonecrosis, malunion, and the need for subsequent major reconstructive surgery (arthroplasty or proximal femoral osteotomy). These were compared across decades of adult life through middle age (<30 years, 30-39 years, 40-49 years, and 50-59 years). RESULTS Overall, treatment failure was observed in 264 of 565 (47%) of all hips. The mean age was 42.2 years, 35.8% of patients were women, and the mean Pauwels angle was 53.8 degrees. Complications and the need for major secondary surgeries increased with each increasing decade of life assessed: 36% of failure occurred in patients <30 years of age, 40% in their 30s, 48% in their 40s, and 57% in their 50s (P < 0.001). Rates of osteonecrosis increased with decades of life (under 30s and 30s vs. 40s vs. 50s developed osteonecrosis in 10%, 10%, 20%, and 27% of hips, P < 0.001), while fixation failure and/or nonunion only increased by decade of life to a level of trend (P = 0.06). Reparative methods varied widely between decade-long age groups, including reduction type (open vs. closed, P < 0.001), reduction quality (P = 0.030), and construct type (cannulated screws vs. fixed angle devices, P = 0.024), while some variables evaluated did not change with age group. CONCLUSIONS Displaced FNFs in young and middle-aged adults are a challenging clinical problem with a high rate of treatment failure. Major complications and the need for complex reconstructive surgery increased greatly by decade of life with the patients in their sixth decade experiencing osteonecrosis at the highest rate seen among patients in the decades studied. Interestingly, treatments provided to patients in their 50s were notably different than those provided to younger patient groups. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Kashmeera Giga
- Texas Christian University School of Medicine, Fort Worth, TX
| | - Thomas Roser
- Texas Christian University School of Medicine, Fort Worth, TX
| | | | - Michael J Beltran
- Department of Orthopedic Surgery, University of Cincinnati, Cincinnati, OH
| | - Brett Crist
- Department of Orthopedic Surgery, University of Missouri, Columbia, MO
| | - Stephen A Sems
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Michael J Gardner
- Department of Orthopedic Surgery, Stanford University, Redwood City, CA
| | - H Claude Sagi
- Department of Orthopedic Surgery, University of Cincinnati, Cincinnati, OH
| | | | - Hassan R Mir
- Orthopaedic Trauma Service, Florida Orthopaedic Institute and University of South Florida, Tampa, FL
| | | | - Phillip Mitchell
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN; and
| | - Paul Tornetta
- Department of Orthopaedic Surgery, Boston University Medical Center, Boston, MA
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Wiik A, Ashdown T, Holloway I. Health economics for intra-capsular hip fractures undertaking fixation. World J Orthop 2024; 15:30-38. [PMID: 38293259 PMCID: PMC10824066 DOI: 10.5312/wjo.v15.i1.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/26/2023] [Accepted: 12/19/2023] [Indexed: 01/16/2024] Open
Abstract
BACKGROUND Hip fracture is a common musculoskeletal injury in the elderly requiring surgery worldwide. The operative mainstay of intra-capsular hip fractures is arthroplasty with a smaller proportion for fixation. AIM To determine the most beneficial method of fixation for patients with intra-capsular hip fractures. METHODS A registered audit from 2012-2018 was conducted on all intra-capsular hip fractures treated with 2 commonly used fixation methods. Patient notes, electronic records and clinical codes for cost benefit were evaluated. A validated quality of life measure was collected at least 1 year after surgery. RESULTS A total of 83 patients were identified with intra-capsular fractures undergoing fixation during the retrospective period. There were 47 cannulated cancellous screw and 36 sliding hip screw fixations with the case mix comparable for age, gender, co-morbidities and fracture configuration. There was no significant difference in blood loss, tip apex distance, radiation exposure, length of stay, radiological union time, collapse, avascular necrosis or re-operation between fixation methods. Logistic regression analysis demonstrated displaced intracapsular hip fractures correlated significantly with an undesirable outcome conferring a relative odds ratio of 7.25. There were 9 (19%) and 4 (11%) patients respectively, who required re-operation. There was no significant difference in health resource group tariff and implant cost with comparable EQ-5D and visual analogue scores. CONCLUSION No significant advantage was identified with differing fixation type, but irrespective there were a high number of patients requiring re-operation. This was predicted by initial fracture displacement and patient age. Arthroplasty may need to be carefully considered for health economics and patient benefit.
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Affiliation(s)
- Anatole Wiik
- Department of Surgery, Trauma and Orthopaedics, London North West University Healthcare, London HA1 3UJ, United Kingdom
| | - Thomas Ashdown
- Department of Surgery, Trauma and Orthopaedics, London North West University Hospital, London HA1 3UJ, United Kingdom
| | - Ian Holloway
- Department of Surgery, Trauma and Orthopaedics, London North West University Hospital, London HA1 3UJ, United Kingdom
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Olansen J, Ibrahim Z, Aaron RK. Management of Garden-I and II Femoral Neck Fractures: Perspectives on Primary Arthroplasty. Orthop Res Rev 2024; 16:1-20. [PMID: 38192746 PMCID: PMC10771782 DOI: 10.2147/orr.s340535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 12/22/2023] [Indexed: 01/10/2024] Open
Abstract
This review compares internal fixation versus arthroplasty in the treatment of nondisplaced femoral neck fractures (FNFs) calling attention to evolving areas of consensus that influence clinical decision-making. The Garden classification system, typically dichotomized into nondisplaced (types I and II) and displaced (types III and IV) fractures, has been used as a guide for surgical decision-making. Conventionally, treatment of nondisplaced FNF in the elderly has been with internal fixation, and treatment of a displaced FNF has been hemi-, or more recently total hip, arthroplasty. Studies over the last decade have raised concern over the appropriate treatment of nondisplaced FNFs due to high rates of reoperation of nondisplaced FNFs treated with internal fixation. Avascular necrosis (AVN), failure of internal fixation, secondary malunion, and pin/nail penetration through the femoral head have all been observed. Several studies have attributed fixation failure to a degree of femoral neck tilt ≥20°, either posteriorly or anteriorly as seen on the lateral X-ray. Because of these observations of fixation failures, the suggestion has been made that arthroplasty be used when the degree of posterior tilt exceeds a threshold of ≥20° tilt with the expectation of diminishing failure of fixation, decreasing the risk of reoperation and preserving function without increasing mortality rate. Frustrating additional analyses are uncertainties over the mechanisms of failure of internal fixation with ≥20° tilt and the persistently substantial 1-year mortality rate after FNF, which has not been influenced by fixation or replacement type. Due to the lack of consensus regarding the determination of the appropriate surgical intervention for nondisplaced FNFs, an improved algorithm for surgical decision-making for these fractures may prove useful.
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Affiliation(s)
- Jon Olansen
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Zainab Ibrahim
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Roy K Aaron
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
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Abdallatif AG, Sharma A, Mahmood T, Aslam N. Complications and Outcomes of the Internal Fixation of Non-displaced Femoral Neck Fracture in Old Patients: A Two-Year Follow-Up. Cureus 2023; 15:e41391. [PMID: 37546038 PMCID: PMC10401487 DOI: 10.7759/cureus.41391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2023] [Indexed: 08/08/2023] Open
Abstract
Background Fractures of the proximal femur are amongst the most common injuries in the elderly population. While there is a clear consensus regarding the management of displaced femoral neck fractures, the management of non-displaced fractures is less clear. Both fixation and arthroplasty are valid treatment options. Internal fixation is a less invasive procedure, but it carries the risks of non-union and avascular necrosis (AVN) of the femoral head. The literature describes varying complication rates associated with these risks. We aim to describe a series of elderly patients above the age of 65 years with non-displaced fractures of the femoral neck who were treated with internal fixation. Our objectives are to determine the union rate and complications in this group and to elucidate the factors that influence these outcomes. Methods We conducted a retrospective review of all patients aged 65 years and older who presented with femoral neck fractures at our level 1 trauma unit between 2018 and 2020. Fractures were classified using the Garden classification system, and only those with Garden 1 or 2 fractures (non-displaced) were included. Preoperative radiographs or intraoperative fluoroscopy images were used to classify fractures using the Pauwels classification. Serial postoperative radiographs and clinical notes (up to 24 months postoperatively) were reviewed to assess the union rate and the development of complications. Both non-union and AVN were analysed for their associations with age, sex, Pauwels grade and comorbidities. A subgroup analysis of the complications was performed to elucidate their association with age groups (<80 and >80 years) and types of fixations (dynamic hip screws {DHS} and cannulated screws). Results A total of 148 patients, consisting of 60 males and 88 females, were included in the analysis. The patients had a mean age of 78.5 years (ranging from 65 to 98 years). The union rate without any degree of AVN was 90.7%, with six non-unions (4.05%) and six patients experiencing AVN (4.05%). No difference in outcome was detected between the two groups based on age. High (type 2 or 3) Pauwels grade (p = 0.05) and treatment with cannulated screws (p = 0.02) were indicated as significant factors for non-union. All patients who developed AVN were noted to have a comorbidity that is known to predispose them to AVN. Conclusion Our series shows a union rate of 90.7%, which is comparable to the union rates reported in other published literature. Our results suggest that age does not independently influence the outcome of fixation for these fractures. We conclude that fractures with vertical orientation (Pauwels grade 2 or 3), when treated with cannulated screws, are more likely to result in non-union. AVN is the second most common complication after non-union, which is also associated with other risk factors for AVN.
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Affiliation(s)
| | - Anirudh Sharma
- Trauma and Orthopaedics, Hinchingbrooke Hospital, Cambridgeshire, GBR
| | - Tariq Mahmood
- Trauma and Orthopaedics, Worcestershire Acute Trust, Worcester, GBR
| | - Nadim Aslam
- Trauma and Orthopaedics, Worcester Royal Hospital, Worcester, GBR
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Park JW, Lee YK, Kim HS, Kim JK, Ha YC, Koo KH. Incidence and Risk Factors of Short Axial Length of the Proximal Femur: A Caution in the Use of Femoral Neck System in Patients with Garden Type I/II Femoral Neck Fractures. Clin Orthop Surg 2023; 15:388-394. [PMID: 37274503 PMCID: PMC10232318 DOI: 10.4055/cios21222] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 05/13/2022] [Accepted: 09/18/2022] [Indexed: 10/26/2023] Open
Abstract
BACKGROUND In 2018, Femoral Neck System (FNS), a dedicated fixator for femoral neck fractures, was introduced. This device has been in increasing use because it provides excellent rotational and angular stability. However, the shortest bolt of FNS is 75 mm long. Thus, it is not usable when the axial length of the proximal femur (ALPF), the distance between the innominate tubercle and the surface of the femoral head, is less than 80 mm. In this study, we investigated the incidence and associated factors of small ALPF (< 80 mm) in femoral neck fracture patients. METHODS We measured the ALPF on preoperative computed tomography (CT) scans of 261 patients (166 women and 55 men), who were operated due to nondisplaced or impacted femoral neck fractures. The ALPF was measured on reconstructed oblique coronal images along the femoral neck. We evaluated the distribution of ALPF, calculated the incidence of small ALPF (< 80 mm), and correlated it with patient's height, weight, body mass index, age, bone mineral density (T-score), and caput-column-diaphysis angle. RESULTS The ALPF ranged from 67.4 mm to 107.1 mm (mean, 88.4 mm; standard deviation, 7.2 mm). In 19 patients (8.6%, 19 / 221), the length was < 80 mm. The ALPF was strongly correlated with height (correlation coefficient = 0.707, R2 = 0.500, p < 0.001) and moderately correlated with weight (correlation coefficient = 0.551, R2 = 0.304, p < 0.001). The T-score was moderately correlated with the ALPF (correlation coefficient = 0.433, R2 = 0.187, p < 0.001). The age was moderately correlated with the ALPF (correlation coefficient =-0.353, R2 = 0.123, p < 0.001). CONCLUSIONS A considerable percentage of femoral neck fracture patients (8.6%) had small proximal femurs (ALPF < 80 mm), which cannot be operated with FNS. We recommend measuring the ALPF using reconstructed oblique coronal CT images or scaled hip radiographs: en face view of the femoral neck prior to surgery in patients with short stature and/or low body weight. If the ALPF is < 80 mm, the surgeon should prepare other fixation devices.
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Affiliation(s)
- Jung-Wee Park
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Young-Kyun Lee
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hong Seok Kim
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea
| | - Jin-Kak Kim
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yong-Chan Ha
- Department of Orthopaedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Kyung-Hoi Koo
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea
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Akcal MA, Eke I, Mutlu T. Femoral Neck Fractures in Elderly Patients With Coxarthrosis and High Dislocation: The Application of Conservative Treatment. Cureus 2023; 15:e35805. [PMID: 37025706 PMCID: PMC10074014 DOI: 10.7759/cureus.35805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2023] [Indexed: 03/08/2023] Open
Abstract
OBJECTIVE In this study, our aim was to evaluate the results obtained by conservative treatment of femoral neck fracture in patients with untreated Crowe type 4 coxarthrosis with high dislocation. METHODS This was was a retrospective study done at the Orthopaedics and Traumatology Clinic in a secondary care public hospital between 2002 and 2022, in Türkiye. Femur neck fractures were evaluated in six patients who had untreated Crowe type 4 coxarthrosis with high dislocation. RESULTS In the study, we had six patients with undiagnosed developmental dysplasia of the hip (DDH) who suffered femoral neck fractures. The youngest among these patients was 76 years old. Conservative treatment (bed rest, analgesics, non-steroidal anti-inflammatory drugs, and, if needed, opiates and low molecular weight heparin for antiembolic treatment) was found to reduce Harris Hip Score (HHS) and Visual Analogue Scale (VAS) scores significantly (p<0,05). Stage 1 sacral decubitus ulcer occurred in two (33.3%) patients. Patients acquired daily activity capacity similar to their situations before fracture within five to six months. None of the patients suffered embolisms and there was no union in the fracture line of the patients. Conclusion: Based on our data, we think that conservative treatment is a remarkable option for these patients, as the complication risks are low and positive results can be obtained. Thus, we may conclude that conservative treatment can be considered in femoral neck fractures of elderly patients with DDH.
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Treatment Failure in Femoral Neck Fractures in Adults Less Than 50 Years of Age: Analysis of 492 Patients Repaired at 26 North American Trauma Centers. J Orthop Trauma 2022; 36:271-279. [PMID: 35703846 DOI: 10.1097/bot.0000000000002355] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/01/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To assess the operative results of femoral neck fractures (FNFs) in young adults in a large multicenter series, specifically focusing on risk factors for treatment failure. DESIGN Large multicenter retrospective cohort series. SETTING Twenty-six North American Level 1 trauma centers. PATIENTS Skeletally mature patients younger than 50 years with displaced and nondisplaced FNFs treated between 2005 and 2017. INTERVENTION Operative repair of FNF. MAIN OUTCOME MEASUREMENTS The main outcome measure is treatment failure: nonunion and/or failed fixation, osteonecrosis, malunion, and need for subsequent major reconstructive surgery (arthroplasty or proximal femoral osteotomy). Logistic regression models were conducted to examine factors associated with treatment failure. RESULTS Of 492 patients with FNFs studied, a major complication and/or subsequent major reconstructive surgery occurred in 45% (52% of 377 displaced fractures and 21% of 115 nondisplaced fractures). Overall, 23% of patients had nonunion/failure of fixation, 12% osteonecrosis type 2b or worse, 15% malunion (>10 mm), and 32% required major reconstructive surgery. Odds of failure were increased with fair-to-poor reduction [odds ratio (OR) = 5.29, 95% confidence interval (CI) = 2.41-13.31], chronic alcohol misuse (OR = 3.08, 95% CI = 1.59-6.38), comminution (OR = 2.63, 95% CI = 1.69-4.13), multiple screw constructs (vs. fixed-angle devices, OR = 1.95, 95% CI = 1.30-2.95), metabolic bone disease (OR = 1.77, 95% CI = 1.17-2.67), and increasing age (OR = 1.03, 95% CI = 1.01-1.06). Women (OR = 0.57, 95% CI = 0.37-0.88), Pauwels angle ≤50 degrees (type 1 or 2; OR = 0.64, 95% CI = 0.41-0.98), or associated femoral shaft fracture (OR = 0.19, 95% CI = 0.10-0.33) had lower odds of failure. CONCLUSIONS FNFs in adults <50 years old remain a difficult clinical and surgical problem, with 45% of patients experiencing major complications and 32% undergoing subsequent major reconstructive surgery. Risk factors for complications after treatment of displaced FNFs were numerous. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Treatment of Valgus-Impacted and Nondisplaced Femoral Neck Fragility Fractures in the Elderly. J Am Acad Orthop Surg 2021; 29:470-477. [PMID: 33720080 DOI: 10.5435/jaaos-d-19-00866] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 02/08/2021] [Indexed: 02/01/2023] Open
Abstract
As the life expectancy of the worldwide population increases, the number of hip fractures in the elderly cohort is expected to grow. It is important for surgeons to critically analyze available treatment options for these injuries, with the goal of optimizing outcomes and minimizing complications. Femoral neck fractures make up approximately half of all hip fractures. Nonoperative treatment of valgus-impacted and nondisplaced (Garden I and II) femoral neck fractures has high rates of secondary displacement, osteonecrosis, and nonunion; only patients with notable risk for perioperative complications are treated nonoperatively. Surgical intervention is the standard of care, with options including internal fixation (IF) with multiple cancellous screws or a sliding hip screw, hemiarthroplasty, or total hip arthroplasty. Patients with a posterior tilt of greater than 20° have a high rate of revision surgery when treated with IF and may benefit from primary arthroplasty. Furthermore, primary arthroplasty has demonstrated lower revision surgery rates and equivalent postoperative mortality when compared with IF. Surgeons should be aware of the functional outcomes, complications, revision surgery rates, and mortality rates associated with each treatment modality to make a patient-specific decision regarding their care.
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Davanzo D, Previtali D, Tamborini S, Filardo G, Fusco A, Bordoni V, Gaffurini P, Candrian C. Comparison of the survivorship between arthroplasty and ORIF for basi-cervical femoral neck fractures in the overall population and in polymorbid patients. Orthop Traumatol Surg Res 2021; 107:102789. [PMID: 33333272 DOI: 10.1016/j.otsr.2020.102789] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 07/14/2020] [Accepted: 07/21/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Femoral neck fractures (FNFs) are associated with high mortality and can be treated with arthroplasty or open reduction and internal fixation (ORIF). For basi-cervical FNFs, there is no agreement on which procedure is better. Do arthroplasty and open reduction with internal fixation (ORIF) have different rates of survival? Do age and comorbidities influence survivorship? HYPOTHESIS Patients who underwent arthroplasty and patients who underwent ORIF have different rates of survival. PATIENTS AND METHODS Survivorship curves, complications, and hospitalisation length were analysed in 154 patients who received hip arthroplasty, and in 72 patients who received ORIF. Age and ASA score were used to divide the patients into sub-groups and perform secondary analyses. RESULTS At 4.9±2.4 years after surgery, 74 patients in the arthroplasty group (48%) and 33 in the ORIF group (45%) had died. The survivorship curves of the two groups showed a non-significant difference. The hospitalisation length was 13.5±8.9 days, with a non-significant difference between groups. There were 130 complications in total: 97 in the arthroplasty patients (19 patients had multiple complications, 52 had only one), 33 in the ORIF patients (4 patients had multiple complications, 29 had only one); the odds ratio was therefore 2.1 (p=0.02). Age, ASA score, Sernbo score, Charlson comorbidity index, and sex (male) were the best predictors of mortality. In the ASA 3-4 sub-group, the survivorship curves showed a lower mortality in the arthroplasty group (p=0.02). DISCUSSION Arthroplasty and ORIF are both valid procedures for the treatment of basi-cervical FNFs, but a high mortality rate is associated with either procedures. There is no difference in terms of survivorship between arthroplasty and ORIF in the overall population, but the presence of comorbidities may favour arthroplasty, which should be considered when managing patients with basi-cervical FNFs. LEVEL OF EVIDENCE III; retrospective, observational study.
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Affiliation(s)
- Diego Davanzo
- Orthopaedic and traumatology unit, Ospedale regionale di Lugano, EOC, Via Tesserete 46, 6900 Lugano, Switzerland (CH)
| | - Davide Previtali
- Orthopaedic and traumatology unit, Ospedale regionale di Lugano, EOC, Via Tesserete 46, 6900 Lugano, Switzerland (CH)
| | - Simone Tamborini
- Orthopaedic and traumatology unit, Ospedale regionale di Lugano, EOC, Via Tesserete 46, 6900 Lugano, Switzerland (CH)
| | - Giuseppe Filardo
- Orthopaedic and traumatology unit, Ospedale regionale di Lugano, EOC, Via Tesserete 46, 6900 Lugano, Switzerland (CH); ATRC, IRCCS Istituto ortopedico Rizzoli, Bologna, Italy
| | | | - Vittorio Bordoni
- Orthopaedic and traumatology unit, Ospedale regionale di Lugano, EOC, Via Tesserete 46, 6900 Lugano, Switzerland (CH).
| | - Paolo Gaffurini
- Orthopaedic and traumatology unit, Ospedale regionale di Lugano, EOC, Via Tesserete 46, 6900 Lugano, Switzerland (CH)
| | - Christian Candrian
- Orthopaedic and traumatology unit, Ospedale regionale di Lugano, EOC, Via Tesserete 46, 6900 Lugano, Switzerland (CH)
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Wang JG, Wu JX, Li YM, Xu YY. Biomechanical analysis of the closed reduction internal fixation with cannulated screw of femoral neck fractures. Medicine (Baltimore) 2021; 100:e24834. [PMID: 33663103 PMCID: PMC7909119 DOI: 10.1097/md.0000000000024834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 01/25/2021] [Indexed: 01/05/2023] Open
Abstract
The influencing factors in closed reduction internal fixation with cannulated screw of femoral neck fractures have not been well investigated. This study evaluated these factors in patients with femoral neck fractures.Fifty-seven patients (36 males and 21 females) diagnosed with femoral neck fracture with the average age of 52.44 ± 15.04 years who underwent closed reduction internal fixation with cannulated screw were included in this study. Data were collected through case report reviews, phone call follow-ups, and outpatient follow-ups to evaluate pre- and postoperative radiograph images. Statistical analysis was performed using Garden classification, binary and multinomial logistic regression analysis by including factors such as patient's age, gender, fracture type, time to fixation, reduction quality, functional recovery period, removal of cannulated screw, and preoperative traction. Logistic regression analysis revealed that age and reduction quality was statistically significant (P < .05) to clinical outcome and other factors were not statistically significant.The main factors affecting clinical outcomes were functional recovery and reduction quality. The biomechanical effects of fixation provide a good foundation for fracture healing. Patient's conditions should be carefully evaluated before selecting reduction procedures to reach an optimal surgical outcome.
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YARADILMIŞ YU, OKKAOĞLU MC, HURİ P, EYİDOĞAN A, DEMİRKALE İ, ALTAY M. Femur boyun kırıklarında kırık lokalizasyonunun instabilite ile ilişkisi: Biyomekanik çalışma. EGE TIP DERGISI 2020. [DOI: 10.19161/etd.790442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Yoon JY, Lee SJ, Yoon KS, Yoon PW. The diagnostic value of SPECT/CT in predicting the occurrence of osteonecrosis following femoral neck fracture: a prospective cohort study. BMC Musculoskelet Disord 2020; 21:517. [PMID: 32746824 PMCID: PMC7397520 DOI: 10.1186/s12891-020-03538-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/23/2020] [Indexed: 12/05/2022] Open
Abstract
Backgrounds One of the most significant complications after a femoral neck fracture is osteonecrosis of the femoral head (ONFH). The concomitant use of single-photon emission computed tomography (SPECT) with computed tomography (CT) increases the sensitivity for detecting the anatomic location and severity of ONFH. In this study, we evaluated the diagnostic value of SPECT/CT for the occurrence of ONFH by quantifying the perfusion status of the femoral head. Methods A total of 30 patients who had multiple pinnings for femur neck fractures were included in this study. We classified the perfusion status into three groups: normal perfusion, decreased perfusion, and avascular groups, and compared the occurrence of femoral head necrosis between them. For quantitative analysis, we evaluated the uptake ratio of both femur heads (head-to-head uptake ratio). If the patient’s contralateral hip was incomparable, we measured the uptake ratio from the superior dome of the ipsilateral acetabulum (head-to-acetabulum uptake ratio). Results Twenty-four patients out of 30 achieved bone union, whereas the others developed ONFH. When the population was divided into intact and defective perfusion groups on scintigraphy, the sensitivity, specificity, and accuracy of the test were 83.3, 75.0, and 76.7%, respectively. The mean head-to-head uptake ratio value with a 95% confidence interval (CI) was 1.10 (95% CI: 0.85–1.36). In the osteonecrosis group, the mean value of the head-to-head uptake ratio was 0.33 (95% CI: 0.28–0.38). In contrast, the ratio was 1.30 (95% CI: 1.03–1.57) in the non-osteonecrosis group, demonstrating a significant difference in the uptake ratio (P < 0.001). When the cutoff value of the uptake ratio was set to 0.5, both the sensitivity and specificity were 100%. There was also a significant difference in the head-to-acetabulum uptake ratio between the two groups (P < 0.001). Conclusions SPECT/CT was useful in evaluating the perfusion status of the femoral head, showing high accuracy in predicting the occurrence of avascular necrosis. To demonstrate the reliability and validity of SPECT/CT, further prospective studies on a larger scale are warranted.
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Affiliation(s)
- Jae Youn Yoon
- Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Gyeonggi-do, Republic of Korea
| | - Soong Joon Lee
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kang Sup Yoon
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Pil Whan Yoon
- Department of Orthopedic Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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Marchand LS, Karns M, Higgins TF, Aoki SK. Femoral Neck Fracture Fixation with a Medial Buttress Plate That Led to Impingement with Hip Flexion: A Case Report. JBJS Case Connect 2020; 9:e21. [PMID: 30921000 DOI: 10.2106/jbjs.cc.18.00135] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
CASE A 47-year-old man with an isolated femoral neck fracture was treated with open reduction and internal fixation with a medial femoral neck buttress plate and a dynamic hip screw. Union was achieved without osteonecrosis of the femoral head. However, hip arthroscopy that was performed for persistent hip pain following the fracture union revealed an intra-articular impingement of the buttress plate and a substantial anterior acetabular chondral injury. CONCLUSIONS To our knowledge, this is the first reported complication associated with the application of a medial buttress plate for a femoral neck fracture. This case report may help surgeons who employ this technique to avoid a similar complication.
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Affiliation(s)
- Lucas S Marchand
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Michael Karns
- Department of Orthopaedic Surgery, Case Western Reserve University, Cleveland, Ohio
| | - Thomas F Higgins
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Stephen K Aoki
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
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14
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Şahin A, Agar A, Gülabi D, Ertürk C. Comparison of dynamic hip screw and antirotation screw with cannulated screw in the treatment of transcervical collum femoris fractures. Jt Dis Relat Surg 2020; 31:320-327. [PMID: 32584732 PMCID: PMC7489184 DOI: 10.5606/ehc.2020.73416] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 03/24/2020] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVES This study aims to compare the results of internal fixation with dynamic hip screw (DHS)/antirotation screw and conventional cannulated screw (CS) for femoral neck fracture. PATIENTS AND METHODS This retrospective study included a total of 78 patients (57 males, 21 females) with collum femoris fractures treated with internal fixation between January 2015 and January 2019. Group 1 comprised 41 patients with a mean age of 45.7 years (range, 19 to 62 years) treated with DHSs/antirotation screws, while group 2 comprised 37 patients with a mean age of 41.9 years (range, 17 to 75 years) treated with CSs. The patients were evaluated for union, avascular necrosis (AVN), femoral neck shortness, operation time, duration of fluoroscopy exposure, and functional outcomes. RESULTS Age, gender, and Garden classification stages were similar in both groups. No significant difference was found between the groups in respect of AVN and non-union rates. The non-union rate was 12.2% in group 1 and 21.6% in group 2 (p>0.05). The duration of fluoroscopy exposure was statistically significantly higher in group 2 (p=0.001) and the operation time was statistically significantly longer in group 1 (p=0.001). In group 2, femoral neck shortness stature was significantly higher (p=0.007). At the final follow-up examination, the Harris hip score was statistically significantly higher in group 1 (p=0.04). CONCLUSION Dynamic hip screw/antirotation screw was a more relevant treatment method for transcervical femoral neck fractures compared to CS with more favorable functional outcomes and less fluoroscopy exposure.
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Affiliation(s)
| | - Anıl Agar
- Kanuni Sultan Süleyman Eğitim ve Araştırma Hastanesi Ortopedi ve Travmatoloji Kliniği, 34303 Küçükçekmece, İstanbul, Türkiye.
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15
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Open Reduction Is Associated With Greater Hazard of Early Reoperation After Internal Fixation of Displaced Femoral Neck Fractures in Adults 18-65 Years. J Orthop Trauma 2020; 34:294-301. [PMID: 32079891 DOI: 10.1097/bot.0000000000001711] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine (1) which factors are associated with the choice to perform an open reduction and (2) by adjusting for these factors, if the choice of reduction method is associated with reoperation. DESIGN Retrospective cohort study with radiograph and chart review. SETTING Twelve Level 1 North American trauma centers. PATIENTS Two hundred thirty-four adults 18-65 years of age with an isolated, displaced, OTA/AO type 31-B2 or type 31-B3 femoral neck fracture treated with internal fixation with minimum of 6-month follow-up or reoperation. Exclusion criteria were pathologic fractures, associated femoral head or shaft fractures, and primary arthroplasty. INTERVENTION Open or closed reduction technique during internal fixation. MAIN OUTCOME Cox proportional hazard of reoperation adjusting for propensity score for open reduction based on injury, demographic, and medical factors. Reduction quality was assessed by 3 senior orthopaedic traumatologists as "acceptable" or "unacceptable" on AP and lateral postoperative radiographs. RESULTS Median follow-up was 1.5 years. One hundred six (45%) patients underwent open reduction. Reduction quality was not significantly affected by open versus closed approach (71% vs. 69% acceptable, P = 0.378). The propensity to receive an open reduction was associated with study center; younger age; male sex; no history of injection drug use, osteoporosis, or cerebrovascular disease; transcervical fracture location; posterior fracture comminution; and surgery within 12 hours. A total of 35 (33%) versus 28 (22%) reoperations occurred after open versus closed reduction (P = 0.056). Open reduction was associated with a 2.4-fold greater propensity-adjusted hazard of reoperation (95% confidence interval 1.3-4.4, P = 0.004). A total of 35 (15%) patients underwent subsequent total hip arthroplasty or hemiarthroplasty. CONCLUSIONS Open reduction of displaced femoral neck fractures in nonelderly adults is associated with a greater hazard of reoperation without significantly improving reduction. Prospective randomized trials are indicated to confirm a causative effect of open versus closed reduction on outcomes after femoral neck fracture. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Park SJ, Ko BS, Moon KH, Lee M. Prediction Value of SPECT/CT in Avascular Necrosis of Femoral Head After Femur Neck Fracture. Geriatr Orthop Surg Rehabil 2019; 10:2151459319872943. [PMID: 31523476 PMCID: PMC6728667 DOI: 10.1177/2151459319872943] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 08/06/2019] [Indexed: 11/17/2022] Open
Abstract
Introduction The aim of this study was to determine the diagnostic value of single-photon emission computed tomography/computed tomography (SPECT/CT) in prediction of avascular necrosis (AVN) after femoral neck fracture and to evaluate whether photon defect in femoral head as seen in SPECT/CT can be an index for choice of surgical method. Methods This study was based on 97 patients who took SPECT/CT after femoral neck fracture from November 2012 to November 2017, with 64 patients with femoral intertrochanteric fracture in which chances of AVN is rare as a comparison group. Among 97 patients with femoral neck fracture, osteosynthesis was conducted in 7 patients with less than 15% of photon defect in damaged femoral head and 7 patients who wanted osteosynthesis, despite photon defect more than 15%, and 83 patients with photon defect more than 25% had arthroplasty. Patient with osteosynthesis was followed up with AVN by conducting magnetic resonance imaging (MRI) in 1 year after the surgery. Results Quantitative analysis of SPECT/CT in 14 patients who had femoral neck osteosynthesis showed that 7 patients with femoral neck fracture showed photon defect of 15% or more, but less than 25% and 3 patients in these were diagnosed with AVN after 1-year follow-up by MRI. Sensitivity and specificity of SPECT/CT in predicting AVN was 100% and 63.6%, respectively, with prediction accuracy of 71.4%. Among 14 patients with femoral neck fracture who had osteosynthesis, photon defect in 3 patients diagnosed with AVN was 19.6% ± 5.2%, but photon defect in 11 patients who was not diagnosed with AVN was 10.7% ± 5.2%, showing statistically significant difference between 2 groups (P = .001). Conclusion Single-photon emission computed tomography/CT in patients with femoral neck fracture is considered to have diagnostic value in predicting occurrence of AVN, and percentage of photon defect is considered to be an useful index in determining the operative method.
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Affiliation(s)
- Sung Jun Park
- Department of Orthopedic Surgery, Inha University Hospital, Incheon, Republic of Korea
| | - Bong Seong Ko
- Department of Orthopedic Surgery, Inha University Hospital, Incheon, Republic of Korea
| | - Kyoung Ho Moon
- Department of Orthopedic Surgery, Inha University Hospital, Incheon, Republic of Korea
| | - Minkyung Lee
- Department of Nuclear Medicine, Inha University Hospital, Incheon, Republic of Korea
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17
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Shehata MSA, Aboelnas MM, Abdulkarim AN, Abdallah AR, Ahmed H, Holton J, Consigliere P, Narvani AA, Sallam AA, Wimhurst JA, Imam MA. Sliding hip screws versus cancellous screws for femoral neck fractures: a systematic review and meta-analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2019; 29:1383-1393. [PMID: 31165917 DOI: 10.1007/s00590-019-02460-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 05/29/2019] [Indexed: 01/24/2023]
Abstract
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.
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Affiliation(s)
| | | | | | | | - Hussien Ahmed
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | | | | | - Ali A Narvani
- Rowley Bristow Orthopaedic Center, St Peter's Hospital, Chertsey, UK
| | - Asser A Sallam
- Department of Orthopedic Surgery and Trauma, Suez Canal University Hospitals, Kilo 4.5 Ring Road, Ismailia, 41111, Egypt.
| | - James A Wimhurst
- Norfolk and Norwich University Hospital, University of East Anglia, Norwich, UK
| | - Mohamed A Imam
- Department of Orthopedic Surgery and Trauma, Suez Canal University Hospitals, Kilo 4.5 Ring Road, Ismailia, 41111, Egypt.,Norfolk and Norwich University Hospital, University of East Anglia, Norwich, UK
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18
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Gumustas S, Tosun HB, Isyar M, Serbest S, Oznam K, Bulut G. Femur neck fracture in young adults, is it really an urgent surgery indication: retrospective clinical study. Pan Afr Med J 2018; 30:112. [PMID: 30364439 PMCID: PMC6195237 DOI: 10.11604/pamj.2018.30.112.13643] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 05/25/2018] [Indexed: 12/11/2022] Open
Abstract
Introduction Femur neck fracture comprises a significant part of intracapsular femur fracture in the intracapsular area of proximal femur and it is mostly seen in elder people. However, these kinds of fractures may be seen in young adults. The present study aims to search factors that affect femoral neck fractures in young adults after surgery carried out by internal determination method. Methods Files of patients who were applied internal determination through closed reduction and cannulated screw because of intracapsular femur neck fractures between 2010 and 2015 were analyzed retrospectively. Fractures were evaluated by means of Garden classification, which is based on radiological appearance. The cases were examined in terms of timing of surgery in two groups. Cases operated in the first 24 hours after trauma consisted of group 1 and after 24 hours group 2. Radiological staging in femoral head avascular necrosis was evaluated by Ficat-Arlet classification system whereas acetabular fractures and hip functionality was evaluated by Letournel and Judet system, which is based on direct graph of fracture line. Results Mean age at the time of surgery for 31 cases included in the study was 40.04 ± 9.63 year. The average duration from injury to surgery was 6.6 (1-20) days. Thirty nine percent of fractures was nondisplaced whereas 61% was displaced. The average follow-up period was 4.9 ± 1.35 years. The rate of nonunion was found 16% and femoral head avascular necrosis 6.4%. According to Judet System, 67.7% of cases showed excellent/good and 32.3% moderate/bad functional results. Six cases had a secondary surgery. Cases who had displaced fractures statistically showed worse functional results and underwent more secondary surgery than patients with nondisplaced fractures (P>0.05). As a result of logistic regression analysis, presence of displacement was a factor negatively affecting the judet score but did not affect the rate of complication. There were no significant differences between the two groups according to the surgical timing in terms of functional outcomes and complications. Conclusion Because of surgical treatment of femoral neck fractures in the first 24 hours does not affect functional outcomes and complication rate, surgery is recommended in optimal conditions. In the case of displacement, care must be taken in terms of poor functional results.
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Affiliation(s)
- Seyitali Gumustas
- Dr Lutfi Kirdar Kartal Training and Research Hospital, Department of Orthopaedics and Traumatology, Istanbul, Turkey
| | - Haci Bayram Tosun
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Adiyaman University, Adiyaman, Turkey
| | - Mehmet Isyar
- Medicalpark Bahcelievler, Department of Orthopaedics and Traumatology, Istanbul, Turkey
| | - Sancar Serbest
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Kirikkale University, Kirikkale, Turkey
| | - Kadir Oznam
- Istanbul Medipol University School of Medicine, Department of Orthopaedic and traumatology, 34214, Istanbul, Turkey
| | - Güven Bulut
- Dr Lutfi Kirdar Kartal Training and Research Hospital, Department of Orthopaedics and Traumatology, Istanbul, Turkey
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19
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Multiple cannulated screws vs. dynamic hip screws for femoral neck fractures. DER ORTHOPADE 2017; 46:954-962. [DOI: 10.1007/s00132-017-3473-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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20
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Verma N, Singh MP, Ul-Haq R, Rajnish RK, Anshuman R. Outcome of bone marrow instillation at fracture site in intracapsular fracture of femoral neck treated by head preserving surgery. Chin J Traumatol 2017; 20:222-225. [PMID: 28679476 PMCID: PMC5555246 DOI: 10.1016/j.cjtee.2017.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 01/16/2017] [Accepted: 02/15/2017] [Indexed: 02/04/2023] Open
Abstract
PURPOSE The aim of present study is to evaluate the outcome of bone marrow instillation at the fracture site in fracture of intracapsular neck femur treated by head preserving surgery. METHODS This study included 32 patients of age group 18-50 years with closed fracture of intracapsular neck femur. Patients were randomized into two groups as per the plan generated via www.randomization.com. The two groups were Group A (control), in which the fracture of intracapsular neck femur was treated by closed reduction and cannulated cancellous screw fixation, and Group B (intervention), in which additional percutaneous autologous bone marrow aspirate instillation at fracture site was done along with cannulated cancellous screw fixation. Postoperatively the union at fracture site and avascular necrosis of the femoral head were assessed on serial plain radiographs at final follow-up. Functional outcome was evaluated by Harris hip score. RESULTS The average follow-up was 19.6 months. Twelve patients in each group had union and 4 patients had signs of nonunion. One patient from each group had avascular necrosis of the femoral head. The average Harris hip score at final follow-up in Group A was 80.50 and in Group B was 75.73, which was found to be not significant. CONCLUSION There is no significant role of adding on bone marrow aspirate instillation at the fracture site in cases of fresh fracture of intracapsular neck femur treated by head preserving surgery in terms of accelerating the bone healing and reducing the incidence of femoral head necrosis.
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Affiliation(s)
- Nikhil Verma
- Department of Orthopaedics, UCMS and Ass. GTBH, Delhi, India.
| | - M P Singh
- Department of Orthopaedics, UCMS and Ass. GTBH, Delhi, India
| | - Rehan Ul-Haq
- Department of Orthopaedics, UCMS and Ass. GTBH, Delhi, India
| | | | - Rahul Anshuman
- Department of Orthopaedics, UCMS and Ass. GTBH, Delhi, India
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21
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Schiffner R, Reiche J, Brodt S, Brinkmann O, Bungartz M, Matziolis G, Schmidt M. A Simple Procedure for the Evaluation of Bone Vitality by Staining with a Tetrazolium Salt. Int J Mol Sci 2017; 18:ijms18081646. [PMID: 28788079 PMCID: PMC5578036 DOI: 10.3390/ijms18081646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 07/25/2017] [Accepted: 07/27/2017] [Indexed: 12/28/2022] Open
Abstract
Presently, no intra-operative method for a direct assessment of bone vitality exists. Therefore, we set out to test the applicability of tetrazolium-based staining on bone samples. The explanted femoral heads of 37 patients were used to obtain either cancellous bone fragments or bone slices. Samples were stained with 2,3,5-triphenyl-2H-tetrazolium chloride (TTC) or 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (thiazolyl blue, MTT) at different times (one to twelve hours) after explantation. Staining was quantified either spectrophotometrically after extraction of the dyes or by densitometric image analysis. TTC-staining of cancellous bone fragments and bone slices, respectively, indicated the detectability of vital cells in both types of samples in a window of up to six hours after explantation. Staining intensity at later time-points was indistinguishable from the staining of untreated samples or sodium azide treated samples, which represent dead cells. In contrast, MTT-staining of bone slices revealed intense unspecific staining, which obscured the evaluation of the vitality of the samples. The lack of a detectable increase of colour intensity in TTC-stained bone samples, which were treated more than six hours after explantation, corresponds to reduced fracture healing. The described simple procedure could provide a basis for an intraoperative decision by the orthopaedic surgeon.
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Affiliation(s)
- René Schiffner
- Orthopaedic Department, Jena University Hospital-Friedrich Schiller University, Campus Eisenberg, Klosterlausnitzer Str. 81, 07607 Eisenberg, Germany.
| | - Juliane Reiche
- Institute for Biochemistry II, Jena University Hospital-Friedrich Schiller University, Nonnenplan 4, 07743 Jena, Germany.
| | - Steffen Brodt
- Orthopaedic Department, Jena University Hospital-Friedrich Schiller University, Campus Eisenberg, Klosterlausnitzer Str. 81, 07607 Eisenberg, Germany.
| | - Olaf Brinkmann
- Orthopaedic Department, Jena University Hospital-Friedrich Schiller University, Campus Eisenberg, Klosterlausnitzer Str. 81, 07607 Eisenberg, Germany.
| | - Matthias Bungartz
- Orthopaedic Department, Jena University Hospital-Friedrich Schiller University, Campus Eisenberg, Klosterlausnitzer Str. 81, 07607 Eisenberg, Germany.
| | - Georg Matziolis
- Orthopaedic Department, Jena University Hospital-Friedrich Schiller University, Campus Eisenberg, Klosterlausnitzer Str. 81, 07607 Eisenberg, Germany.
| | - Martin Schmidt
- Institute for Biochemistry II, Jena University Hospital-Friedrich Schiller University, Nonnenplan 4, 07743 Jena, Germany.
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Kim JW, Ryu JS, Baek S, Byun SE, Chang JS. The timing of bone SPECT to predict osteonecrosis after internal fixation of femur neck fractures. J Orthop Sci 2017; 22:457-462. [PMID: 28089085 DOI: 10.1016/j.jos.2016.12.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 12/01/2016] [Accepted: 12/14/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Bone SPECT can be used after a femur neck fracture to assess the circulation of the femoral head in the immediate postoperative period because the blood supply is one of the major factors affecting bone uptake of radiotracer on bone scintigraphy. The purpose of our present study was to investigate whether osteonecrosis of the femoral head (OFH) after internal fixation of femoral neck fracture could be predicted by early and late bone SPECT. METHODS This retrospective cohort study enrolled 44 patients (33 women; mean age, 66.9 years) who underwent surgical fixation for femoral neck fractures. Early and late bone SPECT images were obtained within 2 weeks postoperatively and at 3 months postoperatively. Patients were followed up for a minimum of 24 months (average, 34 months). RESULTS OFH developed in 9 out of 44 patients but no patient showed nonunion. Seventeen patients with normal femoral head uptake on early bone SPECT were healed. Of 27 patients with decreased femoral head uptake on early bone SPECT, 2 patients developed OFH on radiography before 3 months postoperatively, 18 patients recovered to normal uptake on the late SPECT, and the remaining 7 patients still showed decreased uptake on the late SPECT at 3 months postoperatively. All of these 7 cases finally developed OFH on radiography. CONCLUSION Bone SPECT can reliably predict the possibility of OFH with after femoral neck fracture at least 3 months after surgery, while early bone SPECT showed low specificity. STUDY DESIGN Clinical.
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Affiliation(s)
- Ji Wan Kim
- Department of Orthopedic Surgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Jin-Sook Ryu
- Department of Nuclear Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sora Baek
- Department of Nuclear Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Seong-Eun Byun
- Department of Orthopedic Surgery, CHA Bundang Medical Center, CHA University, Republic of Korea
| | - Jae Suk Chang
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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Evaluation of a vital staining protocol with 2,3,5-triphenyltetrazolium chloride for cancellous bone in a sheep model. Res Vet Sci 2017; 114:131-135. [PMID: 28376370 DOI: 10.1016/j.rvsc.2017.03.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 03/23/2017] [Indexed: 11/24/2022]
Abstract
Decision making on the optimal surgical treatment of fractures often is hampered by the lack of a method for direct assessment of bone vitality. In various contexts, for example to determine the extents of cerebral insults or of myocardial infarctions in experimental studies, tetrazolium based staining procedures of vital cells are widely used. Here, we set out to test the applicability of tetrazolium based staining on bone samples. 8 brains and 26 femoral heads from sheep were used to prepare tissue slices, which were stained with 2,3,5-triphenyltetrazolium chloride (TTC) at various times (1 to 12h) after explantation. Staining of tissue slices was quantified by densitometric image analysis. Spectrophotometry was used for quantification in cultured cells. TTC-staining of tissue slices indicated detectability of vital cells in slices from both tissues up to 4h after explantation. Staining intensity at later time-points was indistinguishable from the staining of untreated samples or sodium azide treated (necrotic cells) controls. We provide experimental evidence that the choice of the optimal surgical approach for the treatment of fractures involving cancellous bone could be aided by a simple staining procedure for vital bone. However, the described procedure depends on the availability of bone specimens (slices). Therefore, search for an improved stain directly applicable to the bone surface is needed.
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Han S, Oh M, Yoon S, Kim J, Kim JW, Chang JS, Ryu JS. Risk Stratification for Avascular Necrosis of the Femoral Head After Internal Fixation of Femoral Neck Fractures by Post-Operative Bone SPECT/CT. Nucl Med Mol Imaging 2016; 51:49-57. [PMID: 28250858 DOI: 10.1007/s13139-016-0443-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 06/23/2016] [Accepted: 07/22/2016] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Avascular necrosis (AVN) of the femoral head is a major complication after internal fixation of a femoral neck fracture and determines the functional prognosis. We investigated postoperative bone single-photon emission computed tomography/computed tomography (SPECT/CT) for assessing the risk of femoral head AVN. METHODS We retrospectively reviewed 53 consecutive patients who underwent bone SPECT/CT within 2 weeks of internal fixation of a femoral neck fracture and follow-up serial hip radiographs over at least 12 months. RESULTS Nine patients developed femoral head AVN. In 15 patients who showed normal uptake on immediate postoperative SPECT/CT, no AVN occurred, whereas 9 of 38 patients who showed cold defects of the femoral head later developed AVN. The negative predictive value of immediate postoperative SPECT/CT for AVN was 100 %, whereas the positive predictive value was 24 %. Among 38 patients with cold defects, 1 developed AVN 3 months postoperatively. A follow-up bone SPECT/CT was performed in the other 37 patients at 2-10 months postoperatively. The follow-up bone SPECT/CT revealed completely normalized femoral head uptake in 27, partially normalized uptake in 8, and persistent cold defects in 2 patients. AVN developed in 3.7 % (1/27), 62.5 % (5/8), and 100 % (2/2) of each group, respectively. CONCLUSIONS According to the time point of imaging, radiotracer uptake patterns of the femoral head on postoperative bone SPECT/CT indicate the risk of AVN after internal fixation of femoral neck fractures differently. Postoperative bone SPECT/CT may help orthopedic surgeons determine the appropriate follow-up of these patients.
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Affiliation(s)
- Sangwon Han
- Department of Nuclear Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Minyoung Oh
- Department of Nuclear Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seokho Yoon
- Department of Nuclear Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jinsoo Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ji-Wan Kim
- Department of Orthopedic Surgery, Haeundae Paik Hospital, Inje University, Busan, Republic of Korea
| | - Jae-Suk Chang
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jin-Sook Ryu
- Department of Nuclear Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Gupta M, Arya RK, Kumar S, Jain VK, Sinha S, Naik AK. Comparative study of multiple cancellous screws versus sliding hip screws in femoral neck fractures of young adults. Chin J Traumatol 2016; 19:209-12. [PMID: 27578376 PMCID: PMC4992136 DOI: 10.1016/j.cjtee.2015.11.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Both cannulated cancellous screw (CCS) and sliding hip screw (SHS) are used in femoral neck fracture fixations, but which is superior is yet to be determined. This study was aimed to compare the clinicoradiological outcome of femoral neck fracture treated with SHS or CCS in young adults. METHODS Adults (16e60 years) with femoral neck fracture were divided into Group 1 fixed with SHS and Group 2 fixed with three CCS after closed reduction. Pain relief, functional recovery and postoperative radiographs at 6 weeks, 3 months, 6 months and then yearly for upto 4 years were analyzed. RESULTS Group 1 (n=40) achieved radiological union at mean of 7.6 months, with the union rate of 87.5% (n=35), avascular necrosis (AVN) rate of 7.5% (n=3) and mean Harris Hip Score (HHS) of 86.15 at the end of 4 years. In Group 2 (n=45) these parameters were union at 7.1 months, union rate of 82.22% (n=37), AVN rate of 6.67% (n=3) and HHS of 88.65. Comparative results were statistically insignificant. CONCLUSION There is no significant difference in clinicoradiological outcome between the two implants.
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Bhandari M, Jin L, See K, Burge R, Gilchrist N, Witvrouw R, Krohn KD, Warner MR, Ahmad QI, Mitlak B. Does Teriparatide Improve Femoral Neck Fracture Healing: Results From A Randomized Placebo-controlled Trial. Clin Orthop Relat Res 2016; 474:1234-44. [PMID: 26932738 PMCID: PMC4814417 DOI: 10.1007/s11999-015-4669-z] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 12/02/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND There is a medical need for therapies that improve hip fracture healing. Teriparatide (Forteo(®)/ Forsteo(®), recombinant human parathyroid hormone) is a bone anabolic drug that is approved for treatment of osteoporosis and glucocorticoid-induced osteoporosis in men and postmenopausal women at high fracture risk. Preclinical and preliminary clinical data also suggest that teriparatide may enhance bone healing. QUESTIONS/PURPOSES We wished to test the hypotheses that treatment with teriparatide versus placebo would improve femoral neck fracture healing after internal fixation as measured by (1) frequency of revision surgery, (2) radiographic fracture healing, and (3) other outcomes including pain control, gait speed, and safety. METHODS We initiated two separate, but identically designed, clinical trials to meet FDA requirements to provide substantial evidence to support approval of a new indication. The two prospective, randomized double-blind, placebo-controlled Phase III studies were designed to evaluate the effect of subcutaneous teriparatide (20 μg/day) for 6 months versus placebo on fracture healing at 24 months. The trials were conducted concurrently with a planned enrollment of 1220 patients per trial. However, enrollment was stopped owing to very slow patient accrual, and an a priori decision was made to pool the results of those studies for statistical analyses before study completion; pooling was specified in both protocols. Randomization was stratified by fixation (sliding hip screw or multiple cancellous screws) and fracture type (displaced or nondisplaced). An independent Central Adjudication Committee reviewed revision surgical procedures and radiographs. A total of 159 patients were randomized in the two trials (81 placebo, 78 teriparatide). The combined program had very low power to detect the originally expected treatment effect but had approximately 80% power to detect a larger difference of 12% between treatment groups for risk of revision surgery. RESULTS The proportion of patients undergoing revision surgery at 12 months was 14% (11 of 81) in the placebo group versus 17% (13 of 78) in the teriparatide group. Central Adjudication Committee review excluded two of these patients treated with placebo from the primary analysis. After exclusions, the proportion of patients who did not undergo revision surgery at 12 months (primary endpoint) was not different between the study and placebo groups, at 88% in the placebo group (90% CI, 0.79-0.93) versus 84% in the teriparatide group (90% CI, 0.75-0.90; p = 0.743). There also were no differences between groups in the proportion of patients achieving radiographic fracture healing at 12 months (75% [61 of 81] placebo versus 73% [57 of 78] teriparatide; odds ratio, 0.89; 90% CI, 0.46-1.72; p = 0.692) or in measures of pain control (such as pain during ambulation, 92% [55 of 62] placebo versus 91% [52 of 57] teriparatide; odds ratio, 0.91; 90% CI, 0.25-3.37; p = 0.681). The frequency of patients reporting adverse events was 49% [40 of 81] in the placebo group versus 45% [35 of 78] in the teriparatide group (p = 0.634) during the 6-month treatment period. CONCLUSIONS The small sample size limited this study's power to detect potential differences, and the results are exploratory. With the patients available, teriparatide did not decrease the risk of revision surgery, improve radiographic signs of fracture healing, or decrease pain compared with the placebo. The adverse event data observed were consistent with the teriparatide safety profile. Functional and health outcome data from the studies may help improve our understanding of patients recovering from femoral neck fractures. Further large controlled studies are required to determine the effect of teriparatide on fracture healing. LEVEL OF EVIDENCE Level II, prospective study.
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Affiliation(s)
- Mohit Bhandari
- Department of Surgery, McMaster University, 293 Wellington Street N, Suite 110, Hamilton, ON L8L8E7 Canada
| | - Ling Jin
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN USA
| | - Kyoungah See
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN USA
| | - Russel Burge
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN USA
| | - Nigel Gilchrist
- Canterbury District Health Board and Canterbury Geriatric Medical Research Trust Research, The Princess Margaret Hospital, Christchurch, New Zealand
| | - Richard Witvrouw
- Department of Traumatology and Orthopaedics, Sint Jan Hospital, Genk, Belgium
| | - Kelly D. Krohn
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN USA
| | - Margaret R. Warner
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN USA
| | - Qasim I. Ahmad
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN USA
| | - Bruce Mitlak
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN USA
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Min BW, Lee KJ, Bae KC, Lee SW, Lee SJ, Choi JH. Result of Internal Fixation for Stable Femoral Neck Fractures in Elderly Patients. Hip Pelvis 2016; 28:43-8. [PMID: 27536643 PMCID: PMC4972878 DOI: 10.5371/hp.2016.28.1.43] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 03/11/2016] [Accepted: 03/11/2016] [Indexed: 11/24/2022] Open
Abstract
Purpose This study was conducted to evaluate the results of internal fixation for stable femoral neck fractures occurring in patients over 65 years old. Materials and Methods Between 2008 and 2014, we evaluated 25 patients over 65 years old with Garden type 1 and 2 femoral neck fractures that were treated with internal fixation after a minimum follow up of 1 year. There were 5 males and 20 females and the average age was 72.3 years (range, 65-84 years) at the time of surgery. Fracture site union, horizontal shortening and complications were evaluated as radiographic parameters and change of walking ability (as measured using Koval walking ability score) was investigated as a clinical parameter. Results Union of fracture site was achieved in 24 out of the 25 cases (96.0%). The average length of horizontal shortening was 6.5 mm (range, 0.2-19.7 mm). At final follow up, 3 cases experienced complications: nonunion (n=1), avascular necrosis (n=1), and subtrochanteric fracture after minor trauma (n=1). Walking ability decreased an average of 1 step at the final follow up. Conclusion Internal fixation for stable femoral neck fractures occurring in patients over 65 years showed satisfactory union rates. However, care should be taken with this technique given the possibility of decreased walking ability resulting from horizontal shortening.
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Affiliation(s)
- Byung-Woo Min
- Department of Orthopedic Surgery, Keimyung University School of Medicine, Daegu, Korea
| | - Kyung-Jae Lee
- Department of Orthopedic Surgery, Keimyung University School of Medicine, Daegu, Korea
| | - Ki-Cheor Bae
- Department of Orthopedic Surgery, Keimyung University School of Medicine, Daegu, Korea
| | - Si-Wuk Lee
- Department of Orthopedic Surgery, Keimyung University School of Medicine, Daegu, Korea
| | - Seok-Jung Lee
- Department of Orthopedic Surgery, Keimyung University School of Medicine, Daegu, Korea
| | - Jung-Hoon Choi
- Department of Orthopedic Surgery, Keimyung University School of Medicine, Daegu, Korea
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Abstract
BACKGROUND The most serious complication of femoral neck fractures in children and adolescents is osteonecrosis. Although a number of factors have been implicated in the development of osteonecrosis, no specific cause-and-effect relationship has been determined. The primary purpose of this study was to determine the prevalence of osteonecrosis in children and adolescents after femoral neck fractures and to identify risk factors for its development. METHODS This retrospective review identified 70 patients between the ages of 1.3 and 18.1 years who were treated for a femoral neck fracture between 2000 and 2011 at a single level I pediatric trauma center and followed until clinical and radiographic union. Demographic information, injury event details, type of surgical treatment, associated injuries, time from injury to treatment, and postoperative alignment were recorded from chart and radiographic review. The primary outcome was the presence of osteonecrosis, which was determined by review of available imaging. Multivariable logistic regression analysis tested age, time to treatment, type of fixation, mechanism of injury, postoperative alignment, and capsular decompression as possible risk factors for the development of osteonecrosis. RESULTS Osteonecrosis occurred in 20 (29%) of the 70 patients. The median time to diagnosis of osteonecrosis was 7.8 months. Multivariable predictors of osteonecrosis included fracture displacement (P=0.01) and fracture location (P=0.02). Patient age, type of fixation, mechanism of injury, capsular decompression, postoperative alignment, and performance of reduction were not predictive of osteonecrosis after femoral neck fracture. Finally, time to treatment also was found to be a positive predictor of osteonecrosis (P=0.004), with osteonecrosis more likely in patients treated in less than 24 hours, but this finding is likely due to confounding because injury severity was closely linked to time to treatment. CONCLUSIONS Regardless of the treatment, the prevalence of osteonecrosis after femoral neck fractures remains high. Recognizing factors that are predictive of the development of osteonecrosis can help surgeons counsel patients and families appropriately about the risk of this complication.
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Sheehan SE, Shyu JY, Weaver MJ, Sodickson AD, Khurana B. Proximal Femoral Fractures: What the Orthopedic Surgeon Wants to Know. Radiographics 2015; 35:1563-84. [PMID: 26186669 DOI: 10.1148/rg.2015140301] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Each year, more than 250,000 hip fractures occur in the United States, resulting in considerable patient mortality and morbidity. The various types of adult proximal femoral fractures require different treatment strategies that depend on a variety of considerations, including the location, morphologic features, injury mechanism, and stability of the fracture, as well as the patient's age and baseline functional status. The authors discuss femoral head, femoral neck, intertrochanteric, and subtrochanteric fractures in terms of injury mechanisms, specific anatomic and biomechanical features, and important diagnostic and management considerations, including the diagnostic utility of imaging modalities. The authors review clinically important classification systems, such as the Pipkin, Garden, Pauwels, and Evans-Jensen classification systems, with emphasis on differentiating subchondral insufficiency fractures from avascular necrosis of the femoral head and typical subtrochanteric fractures from atypical (often bisphosphonate-related) subtrochanteric fractures. In addition, the authors describe the potential complications and management strategies for each fracture type on the basis of the patient's age and physical condition. A clear understanding of these considerations allows the radiologist to better provide appropriate and relevant diagnostic information and management guidance to the orthopedic surgeon.
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Affiliation(s)
- Scott E Sheehan
- From the Department of Radiology, Division of Emergency Radiology (S.E.S., J.Y.S., A.D.S., B.K.), and Department of Orthopedic Surgery (M.J.W.), Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
| | - Jeffrey Y Shyu
- From the Department of Radiology, Division of Emergency Radiology (S.E.S., J.Y.S., A.D.S., B.K.), and Department of Orthopedic Surgery (M.J.W.), Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
| | - Michael J Weaver
- From the Department of Radiology, Division of Emergency Radiology (S.E.S., J.Y.S., A.D.S., B.K.), and Department of Orthopedic Surgery (M.J.W.), Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
| | - Aaron D Sodickson
- From the Department of Radiology, Division of Emergency Radiology (S.E.S., J.Y.S., A.D.S., B.K.), and Department of Orthopedic Surgery (M.J.W.), Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
| | - Bharti Khurana
- From the Department of Radiology, Division of Emergency Radiology (S.E.S., J.Y.S., A.D.S., B.K.), and Department of Orthopedic Surgery (M.J.W.), Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
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Han SK, Song HS, Kim R, Kang SH. Clinical results of treatment of garden type 1 and 2 femoral neck fractures in patients over 70-year old. Eur J Trauma Emerg Surg 2015; 42:191-6. [PMID: 26038046 DOI: 10.1007/s00068-015-0528-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 03/30/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION We retrospectively analyzed the clinical results of treatment of impacted or undisplaced femoral neck fractures (Garden types 1 and 2) by osteosynthesis in elderly patients >70-year old. MATERIALS AND METHODS We retrospectively reviewed the radiological results of 52 patients who were followed up for at least 6 months from April 2002 to December 2008. The average age of the patients was 77.6 years (range 70-97 years), and 38 patients were females. The mean follow-up period was 11.7 months (range 6-19 months). Thirteen cases were Garden type 1 fractures, and 39 were Garden type 2 fractures. We assessed the relationships between the occurrence of complications and age, sex, Garden stage, bone mineral density (BMD), history of contralateral hip fracture, and any additional hip injury. RESULTS Major complications occurred in 18 cases (34.6 %), including nonunion (8 cases), osteonecrosis (6 cases), stress fracture of the subtrochanter (2 cases), excessive pull-out of a screw (1 case), and deep infection (1 case). The development of complications was associated with Garden stage 2, BMD, and additional hip injury. However, other factors were not associated with complications. Reoperations were performed in 16 cases (30.1 %), and 2 of the patients died during follow-up. CONCLUSION A relatively high rate of complications or reoperations developed after treatment of Garden 2 femoral neck fractures in senile patients >70 years of age with osteoporosis. Although internal fixation has been recommended in the literature for undisplaced femoral neck fractures, primary arthroplasty may be a better option for treatment of Garden type 2 fractures in elderly patients.
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Affiliation(s)
- S K Han
- Department of Orthopaedic Surgery, St. Paul's Hospital, College of Medicine, The Catholic University of Korea, Dongdaemun-gu, Seoul, 130-709, Republic of Korea
| | - H S Song
- Department of Orthopaedic Surgery, St. Paul's Hospital, College of Medicine, The Catholic University of Korea, Dongdaemun-gu, Seoul, 130-709, Republic of Korea
| | - R Kim
- Department of Orthopaedic Surgery, St. Paul's Hospital, College of Medicine, The Catholic University of Korea, Dongdaemun-gu, Seoul, 130-709, Republic of Korea
| | - S H Kang
- Department of Orthopaedic Surgery, St. Paul's Hospital, College of Medicine, The Catholic University of Korea, Dongdaemun-gu, Seoul, 130-709, Republic of Korea.
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Papakostidis C, Panagiotopoulos A, Piccioli A, Giannoudis PV. Timing of internal fixation of femoral neck fractures. A systematic review and meta-analysis of the final outcome. Injury 2015; 46:459-66. [PMID: 25616675 DOI: 10.1016/j.injury.2014.12.025] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Accepted: 12/18/2014] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Costas Papakostidis
- "G Hatzikostas" General Hospital, Department of Trauma and Orthopaedics, Makriyianni Av., 45 001 Ioannina, Greece; Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Clarendon Wing, Floor A, Great George Street, Leeds General Infirmary, LS1 3EX Leeds, UK; Cancer Center, "Palazzo Baleani", Teaching Hospital Policlinico Umberto I, Corso Vittorio Emanuele II 244, 00186 Rome, Italy; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, LS7 4SA Leeds, West Yorkshire, UK
| | - Andreas Panagiotopoulos
- "G Hatzikostas" General Hospital, Department of Trauma and Orthopaedics, Makriyianni Av., 45 001 Ioannina, Greece; Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Clarendon Wing, Floor A, Great George Street, Leeds General Infirmary, LS1 3EX Leeds, UK; Cancer Center, "Palazzo Baleani", Teaching Hospital Policlinico Umberto I, Corso Vittorio Emanuele II 244, 00186 Rome, Italy; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, LS7 4SA Leeds, West Yorkshire, UK
| | - Andrea Piccioli
- "G Hatzikostas" General Hospital, Department of Trauma and Orthopaedics, Makriyianni Av., 45 001 Ioannina, Greece; Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Clarendon Wing, Floor A, Great George Street, Leeds General Infirmary, LS1 3EX Leeds, UK; Cancer Center, "Palazzo Baleani", Teaching Hospital Policlinico Umberto I, Corso Vittorio Emanuele II 244, 00186 Rome, Italy; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, LS7 4SA Leeds, West Yorkshire, UK
| | - Peter V Giannoudis
- "G Hatzikostas" General Hospital, Department of Trauma and Orthopaedics, Makriyianni Av., 45 001 Ioannina, Greece; Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Clarendon Wing, Floor A, Great George Street, Leeds General Infirmary, LS1 3EX Leeds, UK; Cancer Center, "Palazzo Baleani", Teaching Hospital Policlinico Umberto I, Corso Vittorio Emanuele II 244, 00186 Rome, Italy; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, LS7 4SA Leeds, West Yorkshire, UK.
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Abstract
Anatomic reduction of femoral neck fractures is difficult to obtain in a closed fashion. Open reduction provides for direct and controlled manipulation of fracture fragments. This can be accomplished via multiple approaches. The anterolateral, or Watson-Jones, approach or Smith-Petersen, or direct anterior, approach are the two most frequently used. Percutaneous techniques have also been described, though they lack the visual confirmation of reduction of a traditional open approach. These can be performed using a fracture table or with a free leg on a radiolucent table in either supine or lateral positions. Knowledge of the hip and pelvis anatomy is crucial for the preservation of critical femoral neck vasculature. Intra-operative fluoroscopy together with direct visualization provides the framework for successful manipulation of the fracture fragments, temporary stabilization, and ultimately fracture fixation.
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Mir H, Collinge C. Application of a medial buttress plate may prevent many treatment failures seen after fixation of vertical femoral neck fractures in young adults. Med Hypotheses 2015; 84:429-33. [PMID: 25744726 DOI: 10.1016/j.mehy.2015.01.029] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Revised: 01/03/2015] [Accepted: 01/21/2015] [Indexed: 01/27/2023]
Abstract
Femoral neck fractures in young adults with normal bone are mostly vertically oriented and may have variable amounts of comminution, which result from shearing forces during high-energy trauma. These factors play a role in the high rate of complications after this injury, including nonunion, malunion, failure of fixation, and avascular necrosis. These problems often occur together and inter-relate, for example, nonunion or malunion frequently result from fixation failure and varus collapse of the femoral head after reconstruction. The orthopaedic surgeon's goals of obtaining and maintaining anatomic reduction until bony union have been addressed by a number of surgical approaches and fixation constructs, however, complications are still common and no consensus exists on how these problematic fractures may be best treated. For optimal treatment of vertical femoral neck fractures, anatomic reduction must be achieved and fixation must be able to resist the high shear forces across the fracture with hip motion, weight-bearing, and muscle tone. Buttress plate fixation is a common method for stabilizing fractures that require resistance to shear forces and stands as one of the basic principles of fracture care. This technique has not been widely applied to this injury pattern. We propose that the concepts of modern fracture care should be applied together for vertical femoral neck fractures in young adults. Specifically, we propose that anatomic reduction and fixation of vertically oriented femoral neck fractures with the addition of a medial buttress plate to resist shearing forces will improve on the historically high rate of complications after these difficult injuries.
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Affiliation(s)
- Hassan Mir
- Department of Orthopedic Surgery and Rehabilitation, Vanderbilt University School of Medicine, Nashville, TN, United States.
| | - Cory Collinge
- Harris Methodist Fort Worth Hospital, Staff Physician John Peter Smith Orthopedic Surgery Residency, Fort Worth, TX, United States.
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The clinical outcomes of early internal fixation for undisplaced femoral neck fractures and early full weight-bearing in elderly patients. Arch Orthop Trauma Surg 2014; 134:941-6. [PMID: 24806536 DOI: 10.1007/s00402-014-2003-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The purpose of the present study was to evaluate the clinical outcomes of early internal fixation for undisplaced femoral neck fractures and early full weight-bearing in patients aged 65 years and older. PATIENTS AND METHODS The records of consecutive patients who underwent surgery for undisplaced femoral neck fractures between 1999 and 2011 were retrospectively reviewed. The patients underwent the surgery as early as possible, and allowed early full weight-bearing. The interval between initial injury and surgery, time to admission and operation, operation time, decrease in hemoglobin, the postoperative day starting to walk, postoperative walking status, and the incidence of any secondary procedures were evaluated. The average patient age was 77.5 years and the average duration of postoperative follow-up was 46.8 months. The patients were divided to two groups to determine the effect of early operation: the early operation group within 24 h on admission, and the late operation group done 24 h after admission. RESULTS Eighty-six percent of surgeries were performed within 48 h of admission. The average operation time was 46 min (range 20-95 min). Transfusions were performed in 6.9 % (4/58) of patients. The mortality rate was 6.9 %, and the rate of complications was 9.3 % (5/54): four cases of avascular necrosis (AVN) and one case of fixation failure. The rate of secondary procedures was 7.4 % (4/54). Seventy-two percent (39/54) of patients recovered their postoperative walking ability to pre-injury levels. CONCLUSION This study demonstrated that early internal fixation of undisplaced femoral neck fractures in elderly patients produced satisfactory clinical outcomes.
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Lee YK, Ha YC, Park C, Koo KH. Trends of surgical treatment in femoral neck fracture: a nationwide study based on claim registry. J Arthroplasty 2013; 28:1839-41. [PMID: 23523212 DOI: 10.1016/j.arth.2013.01.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Accepted: 01/05/2013] [Indexed: 02/06/2023] Open
Abstract
We evaluated current trends of surgical treatment, such as internal fixation and hip arthroplasty, in femoral neck fracture. We assessed annual proportion of the each procedure in patients aged 50 years or more from 2006 to 2011, using the data of Health Insurance Review and Assessment Service (HIRA), which is a national claim registry. The proportion of hip arthroplasty increased while that of internal fixation decreased annually during the 5 years. The proportion of total hip arthroplasty increased in patients aged ≤ 65 years, and that of hemiarthroplasty increased in patients aged ≥ 65 years. The proportional increase of hip arthroplasty seemed to conform to the recent evidence regarding the outcomes of surgical treatments for the femoral neck fracture.
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Affiliation(s)
- Young-Kyun Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Bundang-gu, Seongnam-si, South Korea
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Time to internal fixation of femoral neck fractures in patients under sixty years--does this matter in the development of osteonecrosis of femoral head? INTERNATIONAL ORTHOPAEDICS 2012; 36:2127-32. [PMID: 22829122 DOI: 10.1007/s00264-012-1619-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2012] [Accepted: 07/01/2012] [Indexed: 12/13/2022]
Abstract
PURPOSE Osteonecrosis of femoral head remains a major complication of femoral neck fractures. It has been postulated that early internal fixation drastically reduces the incidence of osteonecrosis of the femoral head. However, there is a paucity of literature looking at the effect of time delay to internal fixation on the development of this late complication. In this study, we aim to assess the effect of time delay and method of internal fixation on the development of osteonecrosis in those less than 60 years of age. METHODS We retrospectively analysed 92 patients less than 60 years of age who presented with intracapsular neck of femur fractures that underwent internal fixation between 1999 and 2009. RESULTS Of the 92 intracapsular fractures, 50 underwent fixation using cannulated screws, 32 using a dynamic hip screw, and ten using a dynamic hip screw with a derotation screw. In total, 13 patients (14.1 %) developed osteonecrosis of the femoral head, the highest incidence being in the cannulated screw fixation group with an osteonecrosis rate of 24 %. We did not find the time delay to internal fixation to be a significant predictor of the development of osteonecrosis. CONCLUSION Our study demonstrated that the method of internal fixation rather than delay in internal fixation was more predictive of osteonecrosis of the femoral head. We did not find support to the current belief that early surgical fixation of neck of femur fractures reduces the risk of osteonecrosis in patients less than 60 years.
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DSA observation of hemodynamic response of femoral head with femoral neck fracture during traction: a pilot study. J Orthop Trauma 2012; 26:407-13. [PMID: 22739255 DOI: 10.1097/bot.0b013e318216dd60] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To investigate the early influence of traction on blood supply to the femur head after femoral neck fractures using digital subtraction angiography (DSA). DESIGN Prospective case series. SETTING University Level I trauma center. PATIENTS Nine patients who sustained a unilateral femoral neck fracture underwent selective femoral artery DSA within 2-23 days after their injury. INTERVENTION DSA of the medial and lateral circumflex femoral artery was performed for all 9 fractured hips before traction. Repeat DSA study of the femoral head circulation was performed after the addition of 3 kg of traction in 7 patients and 5 kg of traction in 6 patients. For comparison, DSA was also performed on the uninjured hip in 8 of the 9 patients. MAIN OUTCOME MEASURE Blood circulation of the femoral head was evaluated by observing morphology of the feeding arteries, perfusion volume, venous drainage, and the circulation time of the microvasculature. RESULTS Femoral neck fracture damaged the retinaculum artery and led to femoral head hemodynamic disorder in all 9 cases. Application of linear traction and repeat DSA decreased femoral head perfusion (faint arterial imaging and delayed venous display) in all patients' retinaculum arteries except the inferior branch compared with the pretraction imaging. These findings were more pronounced as the traction was increased from 3 to 5 kg. These findings were significant (P < 0.05). CONCLUSIONS Traction impairs blood perfusion to the femoral head. Blood flow in the retinacular arteries was reduced and venous drainage impeded. Traction may be one of the major causes of femoral head osteonecrosis after femoral neck fracture.
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Liu YJ, Xu B, Li ZY, Zhang Q, Zhang YZ. Quantitative score system for the surgical decision on adult femoral neck fractures. Orthopedics 2012; 35:e137-43. [PMID: 22310396 DOI: 10.3928/01477447-20120123-09] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Surgical decision making for femoral neck fractures is currently based on factors such as patient age, fracture type, and medical condition, lacking a quantitative standard. The treatment protocol based on such qualitative assessment has poor operability, greatly affected by the surgeon's subjective factors. As a result, a quantitative score system (QSS) focusing on 5 factors--age, fracture type, bone mineral density, activities of daily living, and medical comorbidities--with a total score of 25 is designed to deal with adult femoral neck fractures. The higher the score, the worse the patient's physiological condition. According to our clinical experience, patients with 1 to 11 points should be treated with internal fixation; patients with 12 to 17 points with total hip arthroplasty (THA), and patients with 18 to 22 points with hemiarthroplasty. Patients with 22 to 25 points should be treated with internal fixation due to the high surgical risk of arthroplasty caused by poor physiological condition. Three hundred seventy-five adult femoral neck fractures were treated on the basis of QSS for this 2-year prospective study. Of these, 242 were treated with low-score internal fixation, 60 with THA, 55 with hemiarthroplasty, and 18 with high-score internal fixation. The revision rates 2 years postoperatively in the low-score internal fixation, THA, and hemiarthroplasty groups were 15.3%, 5.0%, and 5.5%, respectively, which were lower than those from a meta-analysis (internal fixation, 35%; THA, 16%). This QSS helps surgical decision making regarding the treatment choice for adult patients with femoral neck fractures, and good results in preliminary clinical practice have been achieved.
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Affiliation(s)
- Yue-Ju Liu
- Department of Trauma, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
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Melvin JS, Matuszewski PE, Scolaro J, Baldwin K, Mehta S, Mehta S. The role of computed tomography in the diagnosis and management of femoral neck fractures in the geriatric patient. Orthopedics 2011; 34:87. [PMID: 21323283 DOI: 10.3928/01477447-20101221-18] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Femoral neck fractures are common in the elderly; however, agreement on classification and treatment varies. It was hypothesized that computed tomography (CT) would increase agreement for Garden Classification and treatment plan over plain radiographs alone. This article presents results of an online survey completed by 32 respondents at a single institution. The survey was comprised of 5 elderly patients with femoral neck fractures using plain radiographs and CT images. Cases were randomly presented in 3 formats: (1) plain radiograph, (2) CT, and (3) plain radiograph and CT together. Patients were described as low-energy trauma, 65 years or older, and cleared for surgery. Garden Classification and treatment plans were queried. A single case was repeated for intraobserver reliability. Kappa was calculated for inter- and intraobserver reliability. The addition of CT and modification of the Garden Classification (nondisplaced vs displaced) improved interobserver agreement in all cases. Participants were 1.7× more likely (P=.042) to change their Modified Garden Classification when CT was added to plain radiograph compared to plain radiograph added to CT. Treatment agreement was slight to fair. Intraobserver agreement varied from slight to moderate. The rate of arthoplasty recommendations was similar across attending subspecialties; however, arthroplasty-trained surgeons were 20 to 60 times more likely to recommend total hip arthroplasty (P=.009) over hemiarthroplasty compared to nonarthroplasty-trained surgeons. The addition of CT to plain radiograph after femoral neck fracture improves Garden Classification agreement. However, treatment agreement was not impacted by CT. Factors other than improved classification agreement appeared to direct surgeons' treatment recommendations.
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Affiliation(s)
- J Stuart Melvin
- Department of Orthopedic Surgery, Carolinas Medical Center, Charlotte, North Carolina 28203, USA.
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Rogmark C, Spetz CL, Garellick G. More intramedullary nails and arthroplasties for treatment of hip fractures in Sweden. Acta Orthop 2010; 81:588-92. [PMID: 20860442 PMCID: PMC3214748 DOI: 10.3109/17453674.2010.506631] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2009] [Accepted: 02/01/2010] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE The surgical methods for treatment of femoral neck fractures and trochanteric hip fractures vary. We describe the changes in Sweden over the period 1998–2007 and the regional differences in treatment. Patients and methods Data on 144,607 patients were drawn from the National Patient Register. RESULTS The proportion of femoral neck fractures treated with arthroplasty increased from 10% in 1998 to 52% in 2007. The use of intramedullary (IM) nails for pertrochanteric fractures increased from 5% to 20%, at the expense of the use of different sliding hip screws. In subtrochanteric fractures, the use of IM nails increased from 32% to 72%. Re-admissions within 180 days due to hip complications were more common after internal fixation for femoral neck fractures than after arthroplasty, and more common after intramedullary nailing of pertrochanteric fractures than after use of sliding hip screws. Treatment varied substantially within Sweden, particularly regarding the use of IM nails. INTERPRETATION An increase in arthroplasties reflects an evidence-based treatment rationale for femoral neck fractures, whereas the increase in use of IM nails in pertrochanteric fractures lacks scientific support. The geographic variations call for national treatment guidelines. Further clinical trials are needed to solve the treatment issues regarding per- and subtrochanteric fractures.
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Affiliation(s)
- Cecilia Rogmark
- Department of Orthopaedics, Lund University, Skane University Hospital, Malmö, Sweden.
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Affiliation(s)
- Joseph Bernstein
- Philadelphia Veterans Hospital, Department of Orthopaedic Surgery, University of Pennsylvania, 2 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104 USA
| | - Jaimo Ahn
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2 Silverstein, Philadelphia, PA 19104 USA
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Management of Displaced Intracapsular Femoral Neck Fracture in Young Adult:hy Complications Are Still So High? Case Report of Posttraumatic Avascular Necrosis in a 30-Year-Old Man and a Brief Review. ACTA ACUST UNITED AC 2009; 67:E163-6. [DOI: 10.1097/ta.0b013e31814b9319] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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[Screw osteosynthesis of proximal femur fractures in children]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2009; 21:349-57. [PMID: 19779689 DOI: 10.1007/s00064-009-1810-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Optimal reposition and stable fixation of M/1 and M/2 fractures are necessary. Careful operation and urgent surgery prevent complications. INDICATIONS M/1 and M/2 fractures of the proximal femur in children > 4 years. CONTRAINDICATIONS E/1 fractures are fixed with Kirschner wires. M/3 fractures are fixed with elastic stable intramedullary nailing. Fractures up to the age of 4 are fixed with Kirschner wires. SURGICAL TECHNIQUE Surgical approach via a lateral incision. Anatomic fixation of the fracture with two to three cannulated screws. POSTOPERATIVE MANAGEMENT No weight bearing during the first 4-6 weeks. Physiotherapy is optional. Magnetic resonance imaging at least 1 year after the fracture or immediately in case of problems to control the vascular situation of the femoral head. RESULTS Due to the rarity of these fractures, only few results from large series have been published. M/1 fractures show a higher complication rate than M/2 fractures. The risk of avascular necrosis has to be estimated at up to 40%.
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Kaushik A, Sankaran B, Varghese M. To study the role of dynamic magnetic resonance imaging in assessing the femoral head vascularity in intracapsular femoral neck fractures. Eur J Radiol 2009; 75:364-75. [PMID: 19625148 DOI: 10.1016/j.ejrad.2009.04.045] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2008] [Accepted: 04/20/2009] [Indexed: 11/28/2022]
Abstract
Intracapsular femoral neck fractures remain unsolved fractures even after improvement in techniques of diagnosis and internal fixation. Individuals who sustain displaced femoral neck fractures are at high risk of developing avascular necrosis and non-union. Although several methods for predicting the viability of femoral head have been reported, they are not effective or widely used because of unreliability, potential complications and technical difficulties. Dynamic MRI was introduced in the recent past as a simple, non-invasive technique to predict the femoral head viability after the femoral neck fractures. In this study role of dynamic MRI was studied in 30 patients with 31 intracapsular femoral neck fractures. Fractures were divided in to three types according to dynamic curve patterns on MRI evaluation and were followed up for 6 months to 2 years to observe the final outcome. Sensitivity, Specificity and the Accuracy of dynamic MRI in predicting vascularity after femoral neck fracture are 87%, 88% and 87%, respectively. Type A or Type B curve pattern is a positive factor to successful osteosynthesis with p value <0.0001 (Chi-square test). This is a statistically significant value. From this finding it can be suggested that the reliability of dynamic curves A and B in predicting maintained vascularity of femoral head is high. This investigation can be used to predict the vascularity of femoral head after intracapsular femoral neck fractures. There was a good correlation between the outcomes of fractures and dynamic MRI curves done within 48 h of injury. This signifies the role of dynamic MRI in predicting the vascularity of femoral head as early as 48 h. A treatment algorithm can be suggested on the basis of dynamic MRI curves. The fractures with Type C dynamic curve should be considered as fractures with poor vascularity of femoral head and measures to enhance the vascularity of femoral head along with rigid internal fixation should be undertaken to promote revascularization process and better healing of fractures. Patients with these fractures should be on longer non-weight bearing ambulation than other patients. To conclude, the dynamic MRI seems to be reliable, non-invasive, sensitive, specific and accurate method of assessing the femoral head vascularity after intracapsular femoral neck fractures as early as 48 h of injury and to predict the outcome of fractures and may be used as a guideline for management of intracapsular femoral neck fractures.
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Affiliation(s)
- Abhishek Kaushik
- Department of Orthopedics, St Stephen’s Hospital, Tis Hazari, Delhi 110054, India.
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Prognostic value of dynamic MRI in assessing post-traumatic femoral head vascularity. Skeletal Radiol 2009; 38:565-9. [PMID: 19266195 DOI: 10.1007/s00256-009-0667-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2008] [Revised: 01/09/2009] [Accepted: 02/12/2009] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The vascular status of femoral heads in the post-traumatic period of intracapsular femoral neck fracture (ICFNF) remains uncertain until the patient actually develops avascular necrosis (AVN). Several methods for predicting the viability of femoral head have been reported, that are not effective or widely used because of unreliability, potential complications, and technical difficulties. The present study involved the use of Dynamic MRI (DMRI) in assessing femoral head vascularity to predict AVN. MATERIALS AND METHODS The role of DMRI was studied prospectively in 30 patients with 31 ICFNF. Fractures were divided in to three types (Type A, B, or C) based on the femoral head vascularity shown by dynamic curve patterns on MRI evaluation. Type A was preserved vascularity, Type B was some decrease in vascularity but still viable while Type C was significantly reduced vascularity. These were followed-up for 6 months to 2 years to observe the final outcome in terms of union, non-union, or AVN. RESULTS We found that Type A curves correlate well with vascular status and Type C curves correlate well with poor vascularity of the femoral heads. No AVN was seen in any of Type A (13/31) or Type B (eight out of 31). Five cases showed AVN and all of them were of Type C dynamic curves. CONCLUSION Dynamic MRI is a reliable tool to evaluate vascularity of femoral heads and thus reduces the uncertainty of outcome of treatment of ICFNFs. DMRI can be a useful tool to formulate a treatment algorithm in management of ICFNF.
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Ruiz-Ibán M, Crespo-Hernández P, Fernández-Roldán S, Díaz-Heredia J, Martínez-Ureña P, Muriel A, Cano-Arana A. Hemiartroplastia cementada tras fractura subcapital de fémur. Análisis de supervivencia. Rev Esp Cir Ortop Traumatol (Engl Ed) 2008. [DOI: 10.1016/s1888-4415(08)74822-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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49
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Ruiz-Ibán M, Crespo-Hernández P, Fernández-Roldán S, Díaz-Heredia J, Martínez-Ureña P, Muriel A, Cano-Arana A. Cemented hemiarthroplasty after a femoral neck fracture. Survivorship analysis. Rev Esp Cir Ortop Traumatol (Engl Ed) 2008. [DOI: 10.1016/s1988-8856(08)70097-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Heetveld MJ, Raaymakers ELFB, Luitse JSK, Nijhof M, Gouma DJ. Femoral neck fractures: can physiologic status determine treatment choice? Clin Orthop Relat Res 2007; 461:203-12. [PMID: 17414163 DOI: 10.1097/blo.0b013e3180574aca] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
In patients with displaced femoral neck fractures, meta-analysis data show revision rates of 35% after internal fixation and 16% after hemiarthroplasty. A published physiologic status score management protocol, which selects for either treatment, suggests lower revision rates can be achieved but it has not been confirmed. The physiologic status score included subscores for mobility, accommodation, bone density, cognition, and American Society of Anesthesiologists class. We asked whether treatment selection with the physiologic status score could indeed reduce revision rates compared with meta-analysis data and whether surgical technique influenced results. In a prospective multicenter 2-year followup trial we enrolled 115 patients selected for internal fixation and 109 for hemiarthroplasty, aged 60 to 90 years. Healthier mobile patients underwent internal fixation and patients with a lower physiologic status score had hemiarthroplasty. The 2-year revision rate was 40% after internal fixation (above meta-analysis rate) and 3% after hemiarthroplasty (below meta-analysis rate). After a panel identified and excluded 15 technical failure cases, patients younger than 80 years with a high physiologic status score had a one in four revision rate of internal fixation, whereas older patients had a one in two revision rate. Although the revision rate was indeed low after hemiarthroplasty, treatment choice based on physiologic status does not substantially improve clinical decision making.
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Affiliation(s)
- Martin J Heetveld
- Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
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