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Zhu X, Wang W, Wang Z, Zhu Y, Li G, Mei J. Bone Grafting Can Promote the Prognosis of Displaced Femoral Neck Fractures: A Follow-up of the Clinical Significance of Bone Defects. Clin Orthop Surg 2023; 15:534-545. [PMID: 37529184 PMCID: PMC10375818 DOI: 10.4055/cios23021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 02/14/2023] [Accepted: 02/16/2023] [Indexed: 08/03/2023] Open
Abstract
Background Femoral neck fractures (FNFs) comprise a large proportion of osteoporotic fractures in Asia. However, the full range of prognostic variables that affect prognosis remains unclear. Here, we aimed to determine whether the severity of bone defects at the fracture site and other variables impact the prognosis of displaced FNFs. Methods We evaluated the incidence of FNF internal fixation failures at regular intervals after surgery in data collected retrospectively. Digital Imaging and Communications in Medicine (DICOM) magnetic resonance imaging data of the displaced FNFs of 204 patients (> 20 years old; mean age, 52.3 years; men, 55.4%) who underwent internal fixation were used to construct three-dimensional (3D) virtual models of the femoral neck region. We calculated the position and volume of bone defect (VBD) using our independently developed algorithm and Mimics software. Each participant was followed up for at least 24 months; complications were noted and correlated with VBD and demographic and clinical variables. Results On the basis of VBD values calculated from virtual reduction models, 57 patients were categorized as having a mild defect, 100 as having a moderate defect, and 47 as having a severe defect. Age (p = 0.046) and VBD (p < 0.001) were significantly correlated with internal fixation failure. Multivariate analysis revealed that severe bone defects were associated with internal fixation failure (adjusted odds ratio [aOR], 23.073; 95% confidence interval [CI], 2.791-190.732) and complications (aOR, 8.945; 95% CI, 1.829-43.749). In patients with a severe defect, bone grafting was inversely associated with internal fixation failure (aOR, 0.022; 95% CI, 0.002-0.268) and complications (aOR, 0.023; 95% CI, 0.002-0.299). Conclusions Bone defect severity was associated with internal fixation failure and other complications. For young adults with large VBDs, bone grafting of the defect can reduce the risk of internal fixation failure. These results provide useful new quantitative information for precisely classifying displaced FNFs and guiding subsequent optimal treatments.
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Affiliation(s)
- Xiaozhong Zhu
- Department of Orthopaedic Surgery, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei Wang
- Department of Biomedical Engineering, The Hong Kong Polytechnic University, Hong Kong, China
| | - Zhiyuan Wang
- Department of Orthopedics, Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yi Zhu
- Department of Orthopaedic Surgery, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Guangyi Li
- Department of Orthopaedic Surgery, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiong Mei
- Department of Orthopaedic Surgery, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Viberg B, Barat S, Rotwitt L, Gundtoft PH. Reoperation for sliding hip screws vs cannulated cancellous screws in femoral neck fractures: A study from the Danish Fracture Database Collaborators. Injury 2022; 53:3805-3809. [PMID: 36167688 DOI: 10.1016/j.injury.2022.09.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 09/19/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION It is still debated whether to use cannulated cancellous screw (CCS) or sliding hip screw (SHS) implants for femoral neck fracture (FNF) patients but there are no studies large enough to evaluate on smaller differences. The aim were to compare the reoperation and mortality rates of a large cohort of FNF patients above 60 years of age with internal fixation using CCS and SHS implants, with stratification by fracture classification. METHODS This register study employed prospectively collected data from 2014 to 2018 from the Danish Fracture Database, including 2-year follow-up and data on age, sex, surgery, comorbidity and fracture classification. Reoperation data was retrieved from the Danish National Patient Register. The primary outcome was major reoperation, defined as re-osteosynthesis, conversion to arthroplasty, non-union surgery, Girdlestone procedure or deep infection 1-year post-surgery. Relative risk (RR) for the CCS group compared with the SHS group was estimated using Cox proportional hazards modelling, adjusted for age, sex and comorbidity (including 95% confidence intervals). RESULTS A total of 2,598 FNFs were included, 1,731 with CCS (67%) and 867 with SHS (33%). The overall 1-year major reoperation rate was 15% with CCS and 13% with SHS, yielding an adjusted RR of 1.10 (0.88; 1.37) for CCS compared to SHS. The adjusted RR was 1.15 (0.77; 1.69) for undisplaced FNF, 1.09 (0.68; 1.75) for displaced FNF and 1.35 (0.94; 1.94) for transcervical FNF, which increased to 1.42 (1.01; 2.00) after 2 years. The minor reoperation rate was higher for CCS (3%) than SHS (1%), yielding an adjusted RR of 2.28 (1.14; 4.51). The adjusted RR for CCS compared to SHS was 0.83 (0.62; 1.12) for 30-day mortality and 0.96 (0.82; 1.14) for 1-year mortality. CONCLUSIONS We found no difference between CCS and SHS in major reoperation rates; however, for transcervical FNF, CCS was associated with higher reoperation rates. Furthermore, CCS was associated with a higher risk of minor reoperation than SHS. There were no differences in mortality rates.
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Affiliation(s)
- Bjarke Viberg
- Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital - University Hospital of Southern Denmark, Kolding, Denmark; Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark.
| | - Siar Barat
- Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital - University Hospital of Southern Denmark, Kolding, Denmark
| | - Lars Rotwitt
- Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital - University Hospital of Southern Denmark, Kolding, Denmark
| | - Per Hviid Gundtoft
- Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital - University Hospital of Southern Denmark, Kolding, Denmark; Department of Orthopaedic Surgery and Traumatology, Aarhus University Hospital, Aarhus, Denmark
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Zhu XZ, Han CX, Ai ZS, Wang W, Wu SH, Zhao KY, Liao P, Mei J. A quantitative study of bone defects in displaced femoral neck fractures based on virtual reduction techniques. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 222:106958. [PMID: 35738093 DOI: 10.1016/j.cmpb.2022.106958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 05/11/2022] [Accepted: 06/14/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Bone defects in femoral neck fractures are strongly associated with the prognosis after internal fixation. However, qualitative analysis of bone defects in femoral neck fractures has already been performed, quantitative studies have not been reported. In this study, we aimed to systematically analyse the morphological characteristics of bone defects in patients with femoral neck fractures using computed tomography (CT) images combined with computer image analysis techniques. METHODS Four hundred and sixty-nine patients with femoral neck fractures from January 2014 to December 2018 at two grade A tertiary hospitals were included. Models were created in Mimics software based on CT images collected within 1 week after injury and then imported into 3-matic software for virtual reduction. The volume of the bone defect (VBD), maximum defect thickness (MDT), extent of the bone defect region (EBDR) , main defect quadrant (MDQ), collapse type and fracture classification were calculated and recorded. RESULTS The EBDR, collapse type and MDT all had a significant positive effect on the VBD (P <0.05), with a more significant effect at higher quantiles. Age also had a significant positive effect on the VBD (P < 0.05), but its effect was more pronounced at lower quantiles. Compared to non-subcapital fractures, subcapital fractures had a positive effect on the VBD only at the 50 and 75% quantiles (P < 0.01). The female sex had a significant negative effect on the VBD compared to the male sex (P < 0.05). CONCLUSION This study established a reliable computer image processing method for quantitative analysis of the VBD in femoral neck fractures and revealed that all patients with femoral neck fractures had bone defects, which can occur at any part of the femoral neck. The EBDR, MDT, collapse type, and patient age and sex were all important risk factors for the extent of the defect and should be taken into account in surgical planning.
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Affiliation(s)
- Xiao-Zhong Zhu
- Department of Orthopaedic Surgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Chun-Xia Han
- Department of Medical Statistic, Tongji University School of Medicine, Shanghai, China
| | - Zi-Sheng Ai
- Department of Medical Statistic, Tongji University School of Medicine, Shanghai, China
| | - Wei Wang
- Department of Biomedical Engineering, The Hong Kong Polytechnic University, Hong Kong, China
| | - Sheng-Hui Wu
- Department of Orthopaedic Surgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Ke-Yang Zhao
- Department of Orthopaedic Surgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Peng Liao
- Department of Orthopaedic Surgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai 200233, China
| | - Jiong Mei
- Department of Orthopaedic Surgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai 200233, China.
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Dai Y, Ni M, Dou B, Wang Z, Zhang Y, Cui X, Ma W, Qin T, Xu X, Mei J. Finite element analysis of necessity of reduction and selection of internal fixation for valgus-impacted femoral neck fracture. Comput Methods Biomech Biomed Engin 2022; 26:846-853. [PMID: 35754380 DOI: 10.1080/10255842.2022.2092727] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
This study compared the biomechanical characteristics of different treatment strategies based on finite element analysis. Posterior tilt and valgus angle were measured on X-ray from ten valgus-impacted femoral neck fractures, and 7 finite element models that were generated to compare the stress and displacement. The results showed that in the intact femur, von Mises stress was concentrated at the medial and inferior sides of the femoral neck. In valgus-impacted femoral neck fractures, von Mises stress was at the same locations but was 5.66 times higher than that in the intact femur. When 3 cannulated screws were used for internal fixation, anatomic reduction diminished the stress at the fracture end from 140.6 to 59.14 MPa, although displacement increased from 0.228 to 0.450 mm. When the fracture was fixed with a sliding hip screw (SHS) + cannulated screw, there was less stress at the fracture end and greater displacement with anatomic reduction than that without reduction (stress: 15.9 vs 37.9 MPa; displacement: 0.329 vs 0.168 mm). Therefore, the SHS + cannulated screw has superior biomechanical stability than 3 cannulated screws, and is recommended following anatomic reduction to treat valgus-compacted femoral neck fractures.
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Affiliation(s)
- Yahui Dai
- Department of Orthopedics, Songjiang District Central Hospital, Shanghai, China
| | - Ming Ni
- Department of Orthopedics, Pudong New Area People's Hospital Affiliated With Shanghai Health University, Shanghai, China.,Department of Science Development, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bang Dou
- Department of Orthopedics, Songjiang District Central Hospital, Shanghai, China
| | - Zhiyuan Wang
- Department of Orthopedics, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yushan Zhang
- Department of Orthopedics, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xueliang Cui
- Department of Orthopedics, Zhongda Hospital Affiliated With Southeast University, Nanjing, China
| | - Wenqian Ma
- Department of Orthopedics, Songjiang District Central Hospital, Shanghai, China
| | - Tao Qin
- Department of Orthopedics, Songjiang District Central Hospital, Shanghai, China
| | - Xiaobin Xu
- Department of Orthopedics, Songjiang District Central Hospital, Shanghai, China
| | - Jiong Mei
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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Singh K, Weitlich JD, Zitsch BP, Schweser KM, Cook JL, Crist BD. Which surgical approach provides maximum visualization and access for open reduction and internal fixation (ORIF) of femoral neck fractures? Injury 2022; 53:1131-1136. [PMID: 34809924 DOI: 10.1016/j.injury.2021.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/01/2021] [Accepted: 11/10/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Appropriate visualization of the femoral neck is critical when performing open reduction and internal fixation (ORIF) of a femoral neck fracture. The purpose of this study was to objectively identify which surgical approach provided the most extensive visualization of the femoral neck during ORIF. Our hypothesis was that the Smith-Petersen approach with rectus release would provide the most extensive visualization. METHODS Ten cadaveric hips were utilized to compare 4 different surgical approaches to the femoral neck: Smith-Petersen (SP), Smith-Petersen with rectus release (SPwR), Watson-Jones (WJ), and Hueter approach. After surgical exposure, calibrated digital images were captured and analyzed using a computer software program to determine the percent-area visualized. Three trained investigators separately assessed each specimen to determine clinical visualization and ability of the surgeon to manually outline anatomic locations of the femoral neck: subcapital, trans-cervical, and basicervical. Data were analyzed for significant (p < 0.05) differences using ANOVA and Fisher Exact tests. RESULTS For calculated percent-visualization, SP and SPwR allowed for significantly more (p = 0.003) visualization than the Hueter and WJ approaches. For surgeon visualization, SP and SPwR were significantly higher (p < 0.029) when compared to WJ. The ability for the individual surgeon to outline the femoral neck's anatomical landmarks was significantly higher (p < 0.049) with SP and Hueter approaches compared with SPwR. CONCLUSION The SP and SPwR provided superior visualization of femoral neck anatomy compared to Hueter and WJ approaches. Similarly, the SP approach allowed for optimal surgeon visualization of and access to clinically relevant femoral neck anatomic landmarks compared to other approaches assessed.
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Affiliation(s)
- Keerat Singh
- University of Missouri Department of Orthopaedic Surgery, 1100 Virginia Ave., Columbia, MO 65212, USA
| | - John D Weitlich
- University of Missouri Department of Orthopaedic Surgery, 1100 Virginia Ave., Columbia, MO 65212, USA
| | - Bradford P Zitsch
- Thompson Laboratory for Regenerative Orthopaedics, 1100 Virginia Ave., Columbia, MO 65212, USA
| | - Kyle M Schweser
- University of Missouri Department of Orthopaedic Surgery, 1100 Virginia Ave., Columbia, MO 65212, USA
| | - James L Cook
- University of Missouri Department of Orthopaedic Surgery, 1100 Virginia Ave., Columbia, MO 65212, USA; University of Missouri School of Medicine, One Hospital Drive, Columbia, MO 65212, USA
| | - Brett D Crist
- University of Missouri Department of Orthopaedic Surgery, 1100 Virginia Ave., Columbia, MO 65212, USA.
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Clinical Outcome and Biomechanical Analysis of Dynamic Hip Screw Combined with Derotation Screw in Treating Displaced Femoral Neck Fractures Based on Different Reduction Qualities in Young Patients (≤65 Years of Age). BIOMED RESEARCH INTERNATIONAL 2022; 2022:9505667. [PMID: 35036442 PMCID: PMC8754672 DOI: 10.1155/2022/9505667] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 12/13/2021] [Indexed: 12/04/2022]
Abstract
Objective To examine the clinical results and biomechanical mechanism of the dynamic hip screw (DHS) and derotation screw (DS) in the treatment of displaced femoral neck fractures (FNF) based on different reduction qualities in young patients (≤65 years of age). Methods All patients with FNF who received closed reduction and internal fixation with DHS+DS from January 2014 to August 2019 were retrospectively analyzed. Data on demographics, surgery, clinical outcomes, and postoperative complications were collected. According to the reduction quality immediately after surgery, all patients were categorized into the positive buttress reduction group (PBRG) and the anatomical reduction group (ARG). The complications and clinical outcomes were compared between the two groups. Meanwhile, the biomechanical mechanism of different reduction qualities was further analyzed with finite element analysis (FEA). The distribution of von Mises stress, the peak stress of internal fixation, and the displacement of the proximal fragment were compared between the two groups. Results A total of 68 patients were included in our study. Among them, 31 were divided into the PBRG while 37 were in the ARG. The surgical time and fluoroscopy time were significantly shorter in the PBRG than in the ARG (p < 0.05). The degree of femoral neck shortening and the varus change of the femoral-neck shaft angle were lower in the PBRG compared to the ARG (p < 0.05). The excellent-good rate of the Harris hip score was higher in the PBRG compared to the ARG (83.9% vs. 64.8%). The FEA results demonstrated that the stress of DHS+CS and the downward displacement of the proximal femoral neck fragment were greater in the ARG than in the PBRG. Conclusion For displaced FNF with difficulty to achieve reduction, DHS+CS combined with positive buttress reduction was an effective treatment in young patients due to better mechanical support, shorter surgical time, less radiation exposure, and higher excellent-good rate of Harris hip score.
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Patterson JT, Ishii K, Tornetta P, Leighton RK, Friess DM, Jones CB, Levine A, Maclean JJ, Miclau T, Mullis BH, Obremskey WT, Ostrum RF, Reid JS, Ruder JA, Saleh A, Schmidt AH, Teague DC, Tsismenakis A, Westberg JR, Morshed S. Smith-Petersen Versus Watson-Jones Approach Does Not Affect Quality of Open Reduction of Femoral Neck Fracture. J Orthop Trauma 2021; 35:517-522. [PMID: 34510125 DOI: 10.1097/bot.0000000000002068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/21/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare immediate quality of open reduction of femoral neck fractures by alternative surgical approaches. DESIGN Retrospective cohort study. SETTING Twelve Level 1 North American trauma centers. PATIENTS Eighty adults 18-65 years of age with isolated, displaced, OTA/AO type 31-B2 or -B3 femoral neck fractures treated with internal fixation. INTERVENTION Thirty-two modified Smith-Petersen anterior approaches versus 48 Watson-Jones anterolateral approaches for open reduction performed by fellowship-trained orthopaedic trauma surgeons. MAIN OUTCOME Reduction quality as assessed by 3 senior orthopaedic traumatologists as "acceptable" or "unacceptable" on AP and lateral postoperative radiographs. RESULTS No difference was observed in the rate of acceptable reduction by modified Smith-Petersen (81%) versus Watson-Jones (81%) approach (risk difference null, 95% confidence interval -17.4% to 17.4%, P = 1.00) with 90.4% panel agreement (Fleiss' weighted κ = 0.63, P < 0.01). Stratified analyses did not identify a significant difference in the rate of acceptable reduction between approaches when stratified by Pauwels angle, basicervical or transcervical fracture location, or posterior comminution. The Smith-Petersen approach afforded a better reduction when preoperative skeletal traction was not applied (RR = 1.67 [95% CI 1.10-2.52] vs. RR = 0.87 [95% CI 0.70-1.08], P = 0.006). CONCLUSIONS No difference was observed in the quality of open reduction of displaced femoral neck fractures in young adults when a Watson-Jones anterolateral approach versus a modified Smith-Petersen anterior approach was performed by orthopaedic trauma surgeons. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Joseph T Patterson
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Keisuke Ishii
- Department of Orthopaedic Surgery, University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA
| | - Paul Tornetta
- Department of Orthopaedic Surgery, Boston University Medical Center, Boston, MA
| | - Ross K Leighton
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, OR
| | - Darin M Friess
- Division of Orthopaedic Surgery, Dalhousie University, Halifax, NS
| | - Clifford B Jones
- Division of Orthopaedic Surgery, Dignity Health Arizona, Creighton Medical School, Phoenix, AZ
| | - Ari Levine
- Department of Orthopaedics, MetroHealth Medical Center, Cleveland, OH
| | - Jeffrey J Maclean
- Department of Orthopaedic Surgery, University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA
| | - Theodore Miclau
- Department of Orthopaedic Surgery, University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA
| | - Brian H Mullis
- Department of Orthopaedic Surgery, Indiana University, Indianapolis, IN
| | - William T Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University, Nashville, TN
| | - Robert F Ostrum
- Department of Orthopaedic Surgery, University of North Carolina, Charlotte, NC
| | - J Spence Reid
- Department of Orthopaedics and Rehabilitation, Penn State University, Hersey Medical Center, Hersey, PA
| | - John A Ruder
- Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, NC
| | - Anas Saleh
- Department of Orthopaedics, MetroHealth Medical Center, Cleveland, OH
| | - Andrew H Schmidt
- Department of Orthopaedic Surgery, Hennepin Healthcare, Minneapolis, MN; and
| | - David C Teague
- Department of Orthopedic Surgery and Rehabilitation, University of Oklahoma, Oklahoma City, OK
| | | | - Jerald R Westberg
- Department of Orthopaedic Surgery, Hennepin Healthcare, Minneapolis, MN; and
| | - Saam Morshed
- Department of Orthopaedic Surgery, University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA
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Marmor M, Guenthner G, Rezaei A, Saam M, Matityahu A. Reporting on quality of reduction and fixation of intertrochanteric fractures-A systematic review. Injury 2021; 52:324-329. [PMID: 33612251 DOI: 10.1016/j.injury.2021.02.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 02/04/2021] [Accepted: 02/06/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Patient outcomes after intertrochanteric fracture fixation is the subject of a large body of published and ongoing clinical research. Fracture reduction and stable fixation are a pre-requisite for achieving optimal results. However, reporting on the quality of postoperative reduction and fixation, has been inconsistent in the literature on intertrochanteric fractures. The purpose of this study was to examine the quality and consistency of reporting of immediate postoperative reduction and fixation in clinical outcome studies of intertrochanteric fracture fixation. METHODS Outcome studies of intertrochanteric fractures, published between 2001 and 2019, were identified using a PubMed. Six journals were identified as having a high impact on intertrochanteric fracture research by either having an impact factor greater than 3.0 or more than 30 published studies fulfilling inclusion criteria. Two independent reviewers reviewed each article for its reporting on immediate post-operative radiographic findings and whether an attempt was made to correlate these findings to outcomes. Quality and consistency of reduction reporting were assessed by recording the type and number of uniquely reported reduction metrics in all of the included studies. RESULTS The reviewers identified 134 papers for the study, of which 110 (82%) reported on immediate postoperative radiographic findings. Of the papers reporting these findings, 84 (76%) reported quantitative measurements. Quantitative reporting changed from 79% in papers published between 2001-2014 to 86% in papers published between 2015-2019. Sixty-one (46%) papers reported Tip-Apex Distance, 56 (42%) reported degree of varus (compared to non-injured side), 42 (31%) reported Neck-Shaft Angle restoration, 31(23%) reported leg-length discrepancy, 18 (13%) reported rotation, 15(11%) reported on the status of the lateral wall, and 6 (4%) reported on calcar (medial buttress) reduction. Sixty-eight (51%) papers that measured reduction found an association between better immediate post-operative reduction and improved outcomes. CONCLUSIONS Despite its recognized influence on outcomes of intertrochanteric fractures, leading peer-reviewed journals do not uniformly report on the immediate postoperative assessment of the quality of reduction and fixation. However, reporting has improved over the past five years. Standardized quantitative metrics will need to be reported in the future to allow meaningful comparisons between studies and accurate assessment of intertrochanteric fracture outcome.
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Affiliation(s)
- Meir Marmor
- Orthopaedic Trauma Institute (OTI), San Francisco General Hospital, University of California, San Francisco (UCSF), 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110, USA.
| | - Guy Guenthner
- University of Minnesota Medical School, 420 Delaware Street Southeast, Minneapolis, MN 55455, USA
| | - Arash Rezaei
- University of Illinois-Chicago Department of Orthopaedics, 1801 West Taylor Street, Suite 2A, Chicago, IL 60612, USA
| | - Morshed Saam
- Orthopaedic Trauma Institute (OTI), San Francisco General Hospital, University of California, San Francisco (UCSF), 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110, USA
| | - Amir Matityahu
- Orthopaedic Trauma Institute (OTI), San Francisco General Hospital, University of California, San Francisco (UCSF), 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110, USA
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Abstract
Femoral neck fractures are frequently treated with open reduction and internal fixation to achieve anatomical reduction. This video demonstrates open reduction internal fixation of a femoral neck fracture in a 59-year-old man, performed through an anterior approach. This approach provides safe and effective access to the femoral neck, including the subcapital and basicervical regions, with excellent direct visualization of the fracture site.
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Ehlinger M, Favreau H, Eichler D, Adam P, Bonnomet F. Early mechanical complications following fixation of proximal femur fractures: From prevention to treatment. Orthop Traumatol Surg Res 2020; 106:S79-S87. [PMID: 31680016 DOI: 10.1016/j.otsr.2019.02.027] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 02/13/2019] [Accepted: 02/13/2019] [Indexed: 02/02/2023]
Abstract
Proximal femur fractures have significant functional repercussions in both older adults (sometimes life-threatening) and younger adults (socioeconomic). This study will review the early mechanical complications (EMC) associated with the fixation of femoral neck (FNF) and trochanteric (TF) fractures. What is the nature of these complications? They consist of incorrect fracture fixation, secondary displacement and/or fixation failure (FNF: 3-10%; TF: 5-7%), and more rarely, secondary fractures distal to the implant. What are the risk factors and how can they be controlled? They are related to the patient (osteoporosis), to the type of fracture (FNF: posterior comminution, magnitude of displacement, vertical fracture line, fracture of calcar/TF: comminution of calcar, lesser trochanter fracture, metaphyseal comminution, lateral cortex fracture, greater trochanter comminution), to the chosen treatment (FNF: triple screw fixation or screw-plate are preferable/TF: all implants suitable for simple fractures, cervicomedullary implants for complex fractures), and to the surgical technique (quality of reduction, implant positioning). How should they be treated? Early revision of internal fixation can be difficult and increases the infection risk. Inter- or subtrochanteric valgus osteotomy leads to satisfactory results but is difficult to carry out. Secondary arthroplasty, which is the preferred option in older adults, leads to good outcomes but is technically more difficult, and has a higher complication rate in EMC of trochanteric fractures. LEVEL OF EVIDENCE: V.
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Affiliation(s)
- Matthieu Ehlinger
- Service de chirurgie orthopédique et de traumatologie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France; Laboratoire ICube, CNRS UMR 7357, 30, boulevard Sébastien-Brant, 67400 Ilkirch, France.
| | - Henri Favreau
- Service de chirurgie orthopédique et de traumatologie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - David Eichler
- Service de chirurgie orthopédique et de traumatologie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - Philippe Adam
- Service de chirurgie orthopédique et de traumatologie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France; Laboratoire ICube, CNRS UMR 7357, 30, boulevard Sébastien-Brant, 67400 Ilkirch, France
| | - François Bonnomet
- Service de chirurgie orthopédique et de traumatologie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
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Lu H, Shen H, Zhou S, Ni W, Jiang D. Biomechanical analysis of the computer-assisted internal fixation of a femoral neck fracture. Genes Dis 2019; 7:448-455. [PMID: 32884999 PMCID: PMC7452504 DOI: 10.1016/j.gendis.2019.04.006] [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] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 04/11/2019] [Indexed: 11/18/2022] Open
Abstract
The number and spatial configuration of the screws will affect the stability and prognosis of the fractures. In our study, we assessed the biomechanical effects of the double-head cannulated compression screw (DhCCS) and ordinary cannulated compression screw (OCCS) for the treatment of femoral neck fractures by using computer finite element analysis. The original digital imaging and communications in medicine (DICOM)data of a proximal femur were imported into Materialise's interactive medical image control system (MIMICS)software for modeling. Both DhCCS and OCCS 3D-models were obtained by using the 3D scan technique. Using the fracture model and internal fixation assembly model with an inverted triangle, two horizontal and vertical distribution were established in UG software. Next, the displacement and stress distribution were calculated in ANSYS software. The displacement value of the femoral head in the DhCCS group was smaller than that in the OCCS group, and the displacement value in the two horizontal groups was smaller than that in the vertical group. The stress distribution in the DhCCS group was concentrated on the screw rod at the fracture block and thread end, while only at the fracture block in the OCCS group. The stress in the horizontal group was more dispersed on the screws than that in the vertical group. DhCCS has reliable stability for the fixation of femoral neck fractures and applied in the clinical work and 2 horizontal fixation can be used when two screws are selected.
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Affiliation(s)
- Hui Lu
- Department of Orthopedic Surgery, The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Rd, Chongqing, 400016, PR China
| | - Hongquan Shen
- Department of Orthopedic Surgery, Jiang Jin Central Hospital of Chongqing, 725 Jiangzhou Avenue, Jiang Jin District, Chongqing, 402260, PR China
| | - Shuqing Zhou
- Department of Orthopedic Surgery, Jiang Jin Central Hospital of Chongqing, 725 Jiangzhou Avenue, Jiang Jin District, Chongqing, 402260, PR China
| | - Weidong Ni
- Department of Orthopedic Surgery, The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Rd, Chongqing, 400016, PR China
| | - Dianming Jiang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Rd, Chongqing, 400016, PR China
- Corresponding author.
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Xiong WF, Chang SM, Zhang YQ, Hu SJ, Du SC. Inferior calcar buttress reduction pattern for displaced femoral neck fractures in young adults: a preliminary report and an effective alternative. J Orthop Surg Res 2019; 14:70. [PMID: 30819226 PMCID: PMC6396447 DOI: 10.1186/s13018-019-1109-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 02/21/2019] [Indexed: 11/16/2022] Open
Abstract
Background Fracture reduction quality is of paramount importance for osteosynthesis. The aim of this study was to report the outcome of an inferior cortical buttress non-anatomic reduction pattern and internal fixation for displaced femoral neck fractures (Garden types III and IV) in young adults. Methods A retrospective analysis of 46 displaced femoral neck fractures was performed, which were treated by closed reduction and internal fixation with parallel cannulated screws. There were 20 males and 26 females, with an average age of 50.3 years (19–60). According to the inferior cortical reduction quality seen in recorded intraoperative fluoroscopy, the patients were divided into two groups. Group I (n = 30) was anatomic cortical apposition as the two inferior cortices were smoothly contacted, and group II (n = 16) was buttress cortical apposition as the two inferior cortices were located in positive support contact (Gotfried reduction pattern). With a mean follow-up of 22.0 months, femoral neck length, neck–shaft angle, and clinical outcomes were compared. Results Thirty-nine patients (84.8%) achieved uneventful fracture union. Complications occurred in seven patients, six in group I (20%) and one in group II (6.3%), including displacement to varus, neck shortening, early fixation failure, nonunion, and avascular necrosis of the femoral head. No significant difference existed in the complication rate between the two groups (p = 0.216). Four patients (13.3%) in group I were converted to prosthetic replacement, but none in group II. Conclusions For closed reduction and fixation of displaced femoral neck fractures in young adults, an inferior cortical buttress reduction pattern, though non-anatomic, can produce sustainable fracture stability and predictable clinical outcomes.
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Affiliation(s)
- Wen-Feng Xiong
- The Department of Orthopaedic Surgery, Yangpu Hospital, Tongji University School of Medicine, 450Tengyue Road, Shanghai, 200090, People's Republic of China
| | - Shi-Min Chang
- The Department of Orthopaedic Surgery, Yangpu Hospital, Tongji University School of Medicine, 450Tengyue Road, Shanghai, 200090, People's Republic of China.
| | - Ying-Qi Zhang
- The Department of Orthopaedic Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200090, People's Republic of China
| | - Sun-Jun Hu
- The Department of Orthopaedic Surgery, Yangpu Hospital, Tongji University School of Medicine, 450Tengyue Road, Shanghai, 200090, People's Republic of China
| | - Shou-Chao Du
- The Department of Orthopaedic Surgery, Yangpu Hospital, Tongji University School of Medicine, 450Tengyue Road, Shanghai, 200090, People's Republic of China
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Hoskins W, Rayner J, Sheehy R, Claireaux H, Bingham R, Santos R, Bucknill A, Griffin XL. The effect of patient, fracture and surgery on outcomes of high energy neck of femur fractures in patients aged 15-50. Hip Int 2019; 29:77-82. [PMID: 29734844 DOI: 10.1177/1120700018761154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION: High-energy femoral neck fractures in young patients can be devastating, with the risk of osteonecrosis, nonunion, malunion and lifelong morbidity. The aim of this study is to define the effects of patient, fracture and surgical factors on the outcome of high-energy femoral neck fractures in patients aged from 15 to 50 years. METHODS: A retrospective review was conducted of high-energy femoral neck fractures in patients aged 15-50 managed surgically at a Level 1 Trauma Centre, using a prospectively recorded trauma database. Low energy trauma (including falls from <1 m), medical conditions adversely affecting bone density, and pathological fractures were excluded. A clinical and radiological review was performed. The primary outcome measures were the development of osteonecrosis or nonunion leading to total hip arthroplasty (THA). Secondary outcome measures included osteotomy or other surgical procedures, quality of reduction and malunion. RESULTS: 32 patients meeting the inclusion criteria were identified between January 2008 and July 2015. The mean follow-up was 58.5 months (range 980-3,048 days). 3 patients (9.4%) required THA. No other surgical procedures were performed. None of the 29 other patients developed radiologically apparent osteonecrosis. Fracture type, displacement, anatomical reduction and fixation type were not statistically significant risk factors affecting these outcomes. For all patients, an average of 8% loss of femoral neck height and 10% femoral neck offset were seen. CONCLUSIONS: At a mean 4.9-year follow-up, the incidence of high-energy femoral neck fractures leading to THA was 9.4%, as a consequence of osteonecrosis or nonunion. Malunion was common.
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Affiliation(s)
- Wayne Hoskins
- 1 Traumaplasty Melbourne, East Melbourne, Victoria, Australia.,2 Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Victoria, Australia
| | - Johnny Rayner
- 3 Department of Orthopaedic Surgery, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Rohan Sheehy
- 3 Department of Orthopaedic Surgery, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Harry Claireaux
- 4 Nuffield Department of Orthopaedics, University of Oxford, Oxford, UK.,5 John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Headington, Oxford, UK
| | - Roger Bingham
- 1 Traumaplasty Melbourne, East Melbourne, Victoria, Australia.,3 Department of Orthopaedic Surgery, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Roselyn Santos
- 6 Trauma Service, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Andrew Bucknill
- 3 Department of Orthopaedic Surgery, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Xavier L Griffin
- 4 Nuffield Department of Orthopaedics, University of Oxford, Oxford, UK.,5 John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Headington, Oxford, UK
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Does the Watson-Jones or Modified Smith-Petersen Approach Provide Superior Exposure for Femoral Neck Fracture Fixation? Clin Orthop Relat Res 2018; 476:1468-1476. [PMID: 29698292 PMCID: PMC6437565 DOI: 10.1097/01.blo.0000533627.07650.bb] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND A well-reduced femoral neck fracture is more likely to heal than a poorly reduced one, and increasing the quality of the surgical exposure makes it easier to achieve anatomic fracture reduction. Two open approaches are in common use for femoral neck fractures, the modified Smith-Petersen and Watson-Jones; however, to our knowledge, the quality of exposure of the femoral neck exposure provided by each approach has not been investigated. QUESTIONS/PURPOSES (1) What is the respective area of exposed femoral neck afforded by the Watson-Jones and modified Smith-Petersen approaches? (2) Is there a difference in the ability to visualize and/or palpate important anatomic landmarks provided by the Watson-Jones and modified Smith-Petersen approaches? METHODS Ten fresh-frozen human pelvi underwent both modified Smith-Petersen (utilizing the caudal extent of the standard Smith-Petersen interval distal to the anterosuperior iliac spine and parallel to the palpable interval between the tensor fascia lata and the sartorius) and Watson-Jones approaches. Dissections were performed by three fellowship-trained orthopaedic traumatologists with extensive experience in both approaches. Exposure (in cm) was quantified with calibrated digital photographs and specialized software. Modified Smith-Petersen approaches were analyzed before and after rectus femoris tenotomy. The ability to visualize and palpate seven clinically relevant anatomic structures (the labrum, femoral head, subcapital femoral neck, basicervical femoral neck, greater trochanter, lesser trochanter, and medial femoral neck) was also recorded. The quantified area of the exposed proximal femur was utilized to compare which approach afforded the largest field of view of the femoral neck and articular surface for assessment of femoral neck fracture and associated femoral head injury. The ability to visualize and palpate surrounding structures was assessed so that we could better understand which approach afforded the ability to assess structures that are relevant to femoral neck fracture reduction and fixation. RESULTS After controlling for age, body mass index, height, and sex, we found the modified Smith-Petersen approach provided a mean of 2.36 cm (95% confidence interval [CI], 0.45-4.28 cm; p = 0.015) additional exposure without rectus femoris tenotomy (p = 0.015) and 3.33 cm (95% CI, 1.42-5.24 cm; p = 0.001) additional exposure with a tenotomy compared with the Watson-Jones approach. The labrum, femoral head, subcapital femoral neck, basicervical femoral neck, and greater trochanter were reliably visible and palpable in both approaches. The lesser trochanter was palpable in all of the modified Smith-Petersen and none of the Watson-Jones approaches (p < 0.001). All modified Smith-Petersen approaches (10 of 10) provided visualization and palpation of the medial femoral neck, whereas visualization of the medial femoral neck was only possible in one of 10 Watson-Jones approaches (p < 0.001) and palpation was possible in eight of 10 Watson-Jones versus all 10 modified Smith-Petersen approaches (p = 0.470). CONCLUSIONS In the hands of surgeons experienced with both surgical approaches to the femoral neck, the modified Smith-Petersen approach, with or without rectus femoris tenotomy, provides superior exposure of the femoral neck and articular surface as well as visualization and palpation of clinically relevant proximal femoral anatomic landmarks compared with the Watson-Jones approach. CLINICAL RELEVANCE Open reduction and internal fixation of a femoral neck fracture is typically performed in a young patient (< 60 years old) with the objective of obtaining anatomic reduction that would not be possible by closed manipulation, thus enhancing healing potential. In the hands of surgeons experienced in both approaches, the modified Smith-Petersen approach offers improved direct access for reduction and fixation. Higher quality reductions and fixation are expected to translate to improved healing potential and outcomes. Although our experimental results are promising, further clinical studies are needed to verify if this larger exposure area imparts increased quality of reduction, healing, and improved outcomes compared with other approaches. The learning curve for the exposure is unclear, but the approach has broad applications and is frequently used in other subspecialties such as for direct anterior THA and pediatric septic hip drainage. Surgeons treating femoral neck fractures with open reduction and fixation should familiarize themselves with the modified Smith-Petersen approach.
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Yin H, Pan Z, Jiang H. Is dynamic locking plate(Targon FN) a better choice for treating of intracapsular hip fracture? A meta-analysis. Int J Surg 2018; 52:30-34. [PMID: 29427750 DOI: 10.1016/j.ijsu.2018.01.044] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 11/12/2017] [Accepted: 01/25/2018] [Indexed: 10/18/2022]
Abstract
PURPOSE The aim of this study was to assess the outcomes of dynamic locking plate (Targon FN) and other alternative implant (cannulated cancellous screws or sliding hip screw) for treating of intracapsular hip fracture. METHODS Relevant clinical trials on the dynamic locking plate and alternative implant treatment for intracapsular hip fracture were retrieved through searching the databases, PubMed, Embase and the Cochrane Central Register of Controlled Trials up to August 2017. Studies that investigated the comparing effectiveness or complications between both groups and provided sufficient data of interest were included in this meta-analysis. RESULTS Four studies involving 385 intracapsular hip fractures were included. The differences in nonunion [odds ratio (OR) 0.16,95% confidence interval (CI) 0.05-0.49], revision (OR 0.56, 95%CI 0.32-0.96) and replacement rate (OR 0.26, 95%CI 0.10-0.69) were statistically significant between dynamic locking plate and alternative implant group. There was no statistically significant difference in osteonecrosis (OR1.73, 95%CI0.59-5.02), cut-out (OR0.89,95%CI0.23-3.46)and non orthopaedics complication rate (OR0.73, 95% CI 0.38-1.41). CONCLUSIONS The available evidence indicate that dynamic locking plate offers a superior outcome in comparison with alternative implants and reduces the nonunion, revision and replacement rates for treating intracapsular hip fractures, but does not affect the osteonecrosis, cutout and non-orthopadeics complication rate. Decisions should be made in accordance with specific conditions for clinical application.
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Affiliation(s)
- Hao Yin
- Department of Orthopaedics, The Third Affiliated Hospital of AnHui Medical University, China.
| | - Zhengjun Pan
- Department of Orthopaedics, The Third Affiliated Hospital of AnHui Medical University, China
| | - Hua Jiang
- Department of Orthopaedics, The Third Affiliated Hospital of AnHui Medical University, China
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Aihara LJ, Nanni RA, Carvalho MS, Zamboni C, Durigan JR, Hungria Neto JS, Mercadante MT, Christian RW, Hungria JOS. Late postoperative analysis of the tip-apex distance (TAD) in pertrochanteric fractures: is there an accommodation of the implant within the bone? Injury 2017; 48 Suppl 4:S54-S56. [PMID: 29145969 DOI: 10.1016/s0020-1383(17)30776-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION This study measured the tip-apex distance (TAD) values in the immediate postoperative period and following weight-bearing and fracture impaction in patients undergoing osteosynthesis with dynamic hip screw and cephalomedullary nail. OBJECTIVE To correlate the Baumgaertner index in the immediate postoperative period with values obtained after impaction of the fracture with the accommodation of the cephalic implant in the femoral head. PATIENTS AND METHODS Radiographic TAD measurements were taken with AGFA-VIEW® of 82 patients with a mean age of 72 years with pertrochanteric fractures who were operated on and the fracture fixed with DHS- Synthes®, TFN-Synthes®, or Gamma Nail III-Stryker® in the immediate postoperative period, and following weight-bearing and fracture impaction (mean 3-8 weeks after surgery). RESULTS The overall average TAD decreased from 20.3mm to 18.2mm. Regardless of the instability of the fracture, the age of the patient or the implant used, TAD decreased between the immediate postoperative period and following fracture impaction. CONCLUSION The osteosynthesis of pertrochanteric fractures was associated with important accommodation of the cephalic implant in the femoral head with decreased TAD values after weight-bearing.
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Affiliation(s)
- Leandro Jun Aihara
- Irmandade da Santa Casa de Misericóridia de São Paulo, São Paulo, Brazil.
| | | | | | - Caio Zamboni
- Irmandade da Santa Casa de Misericóridia de São Paulo, São Paulo, Brazil
| | - Jorge R Durigan
- Irmandade da Santa Casa de Misericóridia de São Paulo, São Paulo, Brazil
| | | | - Marcelo T Mercadante
- Irmandade da Santa Casa de Misericóridia de São Paulo, São Paulo, Brazil; Santa Casa de Sao Paulo School of Medical Sciences, São Paulo, Brazil
| | - Ralph W Christian
- Irmandade da Santa Casa de Misericóridia de São Paulo, São Paulo, Brazil; Santa Casa de Sao Paulo School of Medical Sciences, São Paulo, Brazil
| | - José O S Hungria
- Irmandade da Santa Casa de Misericóridia de São Paulo, São Paulo, Brazil
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Abstract
OBJECTIVES Avascular necrosis (AVN) of the femoral head is a devastating complication following fixation of femoral neck fractures in younger adults. In this study, we investigate the prognostic utility of disuse osteopenia. DESIGN Retrospective study. SETTING Three academic Level 1 trauma centers. PATIENTS One hundred twenty patients younger than 60 years treated for a femoral neck fracture. INTERVENTION N/A. MAIN OUTCOME MEASURES The presence of sclerosis or osteopenia, compared to the contralateral femoral head, was measured 6 weeks from injury both subjectively and using a novel radiographic measure, the relative density ratio (RDR). The outcome measure was radiographic development of AVN. RESULTS The presence of relative sclerosis was associated with AVN and overall treatment failure. Patients with subjective relative sclerosis had a 12.6 (95% confidence interval, 2.9-61.3; P < 0.001) times higher odds of developing AVN. Multiple logistic regression showed that for every 0.10 increase in the RDR, there was a 5.2 increase in the odds (95% confidence interval, 2.1-26.9; P = 0.009) of developing AVN. Patients with an RDR of ≥1.2 have an 80% probability of AVN, whereas those with an RDR ≤0.8 have a <1% probability of developing AVN. CONCLUSIONS Disuse osteopenia detected on 6-week radiographs is a favorable prognostic sign following fixation of femoral neck fractures. Patients who have relative sclerosis of the femoral head at 6-week follow-up are at a higher risk of developing AVN. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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18
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Wong TM. Commentary: Dynamic hip screw fixation versus multiple screw fixation for intracapsular hip fracture. J Orthop Surg (Hong Kong) 2016; 24:144. [PMID: 27574249 DOI: 10.1177/1602400202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- T M Wong
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, The University of Hong Kong, Hong Kong & Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, The University of Hong Kong Shenzhen Hospital, Shenzhen, China
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Ohsawa S, Miura A, Yagyu M, Oizumi A, Yamada E. Assertive rehabilitation for intracapsular fracture of the proximal femur. Clin Rehabil 2016; 21:36-40. [PMID: 17213239 DOI: 10.1177/0269215506069243] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To study the impact of assertive conservative therapy on walking in frail elderly patients with intracapsular fracture of the proximal femaur. Design: Prospective non-randomized controlled trial. Setting: Two private geriatric rehabilitation hospitals. Subjects: From October 1997 to December 2004, 20 patients, not indicated for surgery, were treated with conservative therapy. There were 18 women and 2 men, and their ages were 87.1±4.2 (mean ±SD) years. All of them could walk before hip fracture. Interventions: Thirteen patients accepted our assertive therapy, which consisted of standing on the fractured limb and walking in parallel bars as soon as possible. Seven patients refused our methods and were conventionally treated; the injured limb was immobilized under skin traction, and then they gradually tried to use a wheelchair for pain reduction. Main measures: We used the following measures before therapy and six months after: Merle d'Aubigné & Postel's Hip Score, Functional Independence Measure (FIM) and face pain scale. Results: The two groups were similar demographically. All patients except one (n = 12) responded to our method and could walk. However, the patients treated with the conventional method (n = 7) did not recover the ability to walk. The mean FIM (transfer and locomotion, five items) was 18.2 ±7.9 points in the former and 9.4 ± 4.3 points in the latter. Conclusion: Assertive rehabilitation was more effective at restoring the ambulatory ability of frail elderly patients with intracapsular fracture of the hip than the conventional method.
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Affiliation(s)
- Suguru Ohsawa
- Department of Rehabilitation Medicine, Osaka Rosai Hospital, Osaka, Japan.
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Hartel MJ, Mandani SM, Nuechtern J, Stiel N, Lehmann W, Rueger JM, Grossterlinden LG. On-table decision-making in intracapsular hip fracture surgery: mid-term results of a pilot study. Arch Orthop Trauma Surg 2016; 136:913-9. [PMID: 27155882 DOI: 10.1007/s00402-016-2469-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Indexed: 02/06/2023]
Abstract
INTRODUCTION At the present time, it is generally recommended to use hip replacement in dislocated fractures to avoid failure after internal fixation. A problem is that previous research has demonstrated that observers have problems in discriminating between dislocated and undislocated fractures. A possible solution to this problem would be to use arthroplasty in the majority of the cases. However, this also means that many fractures with the potential for uneventful healing would be replaced. MATERIALS AND METHODS In the current investigation, the mid-term outcome was recorded for patients with intracapsular hip fractures who were treated with either internal fixation or arthroplasty. A novel treatment algorithm was employed. After careful exclusion of cases with known risk factors for failure after internal fixation, a technique called on-table decision was used to identify suitable patients for internal fixation. RESULTS A total of 72 patients with intracapsular hip fractures were studied with a median follow-up time of 12 months (IQR 8-15.25 months). Nineteen (19) patients (26 %) were excluded in the selection process, leaving 53 (74 %) for on-table decision-making. Thirty patients (42 %) were identified as suitable for internal fixation and gave anatomically stable closed reductions. Two of these patients (7 %) exhibited non-unions and one (3 %) avascular necrosis. CONCLUSIONS The mid-term outcome after internal fixation is promising. The careful selection process may be helpful in identifying fracture patterns for which internal fixation may be considered as a safe and less invasive alternative to hip arthroplasty.
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Affiliation(s)
- Maximilian J Hartel
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Shahab Maafi Mandani
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Jakob Nuechtern
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Norbert Stiel
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Wolfgang Lehmann
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Johannes M Rueger
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Lars G Grossterlinden
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
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Abstract
OBJECTIVES To report outcomes of a cohort with displaced femoral neck fractures (FNFs) treated with a length/angle-stable construct augmented with an endosteal fibular allograft serving as a biologic dowel. DESIGN Prospective. SETTING Level I Trauma Center. PATIENTS The study group consists of 27 patients with isolated FNF surgically treated by a single surgeon. INTERVENTION Open reduction of the femoral neck, fixed with a length- and angle-stable construct of 2 fully threaded cannulated screws augmented with an endosteal fibular allograft serving as a biologic dowel. MAIN OUTCOME MEASUREMENTS Clinical and radiographic outcomes of the fixation construct and the viability of both the femoral head and the fibular allograft, host response to the allograft and osseous union were evaluated using a specialized sequence of contrast-enhanced magnetic resonance imaging (MRI) obtained at 3 and 12 months postoperatively. RESULTS This construct resulted in high union rates (89%; 24 of 27). Two patients suffered early catastrophic failure and 1 patient developed fracture nonunion, all of wish underwent uneventful conversion to total hip arthroplasty. Three additional patients (11%) had removal of symptomatic implants. The clinical and radiographic outcomes were excellent. Twelve-month MRIs revealed either partial or complete osseous incorporation of 86% the fibular allografts without signs of adverse reaction of the host to the allograft. Femoral head osteonecrosis segments were noted in 76% of patients on MRI; however, radiographically, there were no signs of osteonecrosis or segmental collapse. CONCLUSIONS The fibular allograft reconstructs the comminuted femoral neck, and the osteointegration overtime increases the strength of the host bone-graft interface. This added strength seems to provide the stability needed to better preserve the intraoperative reduction, obtain good outcomes, and reduce the complications associated with FNF. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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A comparative study between multiple cannulated screws and dynamic hip screw for fixation of femoral neck fracture in adults. INTERNATIONAL ORTHOPAEDICS 2015; 39:2069-71. [PMID: 26152248 DOI: 10.1007/s00264-015-2881-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Accepted: 05/03/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE In younger adults with fractures of the femoral neck, anatomic reduction is compulsory and maintaining the reduction is crucial. Both cannulated screws and dynamic hip screw (DHS) have the capacity of compression in the fracture site but the strength for keeping reduction is not the same. The aim of this study was to compare the results with fixations of the femoral neck fractures with cannulated screws versus dynamic hip screw. METHODS This is a randomized clinical trial study on 58 cases with a minimum of one year follow-up. Leg length discrepancy, Harris Hip Score, infection, avascular necrosis of femoral head, and union of the fracture site were evaluated. RESULTS There were two failures in the first trimester in the cannulated screw group and three more failures in the second and third trimesters in this group. In the DHS group, there was no reduction and fixation failure in the follow-up period. There was no fixation failure (0 %) in Group B (DHS) but there were five fixation failures (18 %) in Group A (screw), and there is significant difference between the groups (p < 0.001). The rate of avascular necrosis was the same in both groups. CONCLUSIONS It seems to us that in our practice the fixation of femoral neck fracture in young adults with the DHS is a better option compared with the osteosynthsis with multiple cannulated screws.
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Deakin DE, Guy P, O'Brien PJ, Blachut PA, Lefaivre KA. Managing failed fixation: valgus osteotomy for femoral neck nonunion. Injury 2015; 46:492-6. [PMID: 25530407 DOI: 10.1016/j.injury.2014.11.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Revised: 10/27/2014] [Accepted: 11/17/2014] [Indexed: 02/02/2023]
Abstract
Femoral neck non union is a relatively uncommon complication following intracapsular hip fracture in the young patient. Almost all patients with femoral neck non union are symptomatic for which they will require some form of revision surgery. This review discusses the role of valgus osteotomy in managing the younger patient with femoral neck non union.
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Affiliation(s)
- D E Deakin
- Department of Orthopaedic Surgery, University of British Columbia, Vancouver General Hospital, Vancouver, Canada
| | - P Guy
- Department of Orthopaedic Surgery, University of British Columbia, Vancouver General Hospital, Vancouver, Canada
| | - P J O'Brien
- Department of Orthopaedic Surgery, University of British Columbia, Vancouver General Hospital, Vancouver, Canada
| | - P A Blachut
- Department of Orthopaedic Surgery, University of British Columbia, Vancouver General Hospital, Vancouver, Canada
| | - K A Lefaivre
- Department of Orthopaedic Surgery, University of British Columbia, Vancouver General Hospital, Vancouver, Canada.
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Abstract
Femoral neck fractures are a commonly encountered injury in orthopaedic practice and result in significant morbidity and mortality. It is essential that surgeons are able to recognize specific fracture patterns and patient characteristics that indicate the use of particular implants and methods to effectively manage these injuries. Use of the Garden and Pauwels classification systems has remained the practical mainstay of femoral neck fracture characterization that help dictate appropriate treatment. Operative options include in situ fixation, closed or open reduction and internal fixation, hemiarthroplasty, and total hip arthroplasty. Recent reports demonstrate diversity among orthopaedic surgeons in regard to the optimal treatment of femoral neck fractures and changing trends in management. The present discussion focuses on the current indications and methods for femoral neck fracture management to provide direction with respect to appropriate and effective care of these injuries.
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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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Filipov O, Gueorguiev B. Unique stability of femoral neck fractures treated with the novel biplane double-supported screw fixation method: a biomechanical cadaver study. Injury 2015; 46:218-26. [PMID: 25527457 DOI: 10.1016/j.injury.2014.11.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2014] [Revised: 10/27/2014] [Accepted: 11/17/2014] [Indexed: 02/02/2023]
Abstract
UNLABELLED Osteosynthesis of femoral neck fractures is related to 20-46% complication rate. Filipov's novel method for biplane double-supported screw fixation (BDSF), using three cannulated screws, has demonstrated excellent clinical results since 2007. Its two calcar-buttressed screws are oriented in different coronal inclinations with steeper angles to the diaphyseal axis and intended to provide constant fixation strength under different loading situations. The aim of this study was to biomechanically evaluate BDSF fixation strength and compare it with the conventional fixation (CFIX) using three parallel cannulated screws. METHODS Eight fresh-frozen and six embalmed human femoral pairs with simulated AO/OTA31-B2.2 fracture were fixed applying either CFIX or BDSF. Quasistatic tests were performed in anteroposterior (AP) bending, followed by axial quasistatic, cyclic and destructive quasistatic tests run in 10° flexion with 7° or 16° varus specimen inclination. RESULTS Initial axial stiffness was significantly higher for BDSF in comparison with CFIX at 7° inclination (p=0.02) and not significantly different between BDSF and CFIX at 16° inclination. Compared with the intact state, it decreased significantly at 7° inclination only for CFIX (p=0.01), but not for BDSF. Interfragmentary displacement during cyclic testing was significantly smaller for BDSF than CFIX at 7° inclination (p≤0.04) and not significantly different between BDSF and CFIX at 16° inclination. Failure load did not differ significantly between BDSF and CFIX at both inclinations. CONCLUSIONS Femoral neck fracture stability can be substantially increased applying BDSF due to better cortical screw support and screw orientation. Having two calcar-buttressed screws oriented in different inclinations, BDSF can enhance constant stability during various patient activities. The more unstable the situation, the better BDSF stability is in comparison to CFIX.
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Affiliation(s)
- Orlin Filipov
- Vitosha Hospital, Simeonovsko Shose Str. 108-B, 1700 Sofia, Bulgaria.
| | - Boyko Gueorguiev
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland
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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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Araujo TPF, Guimaraes TM, Andrade-Silva FB, Kojima KE, Silva JDS. Influence of time to surgery on the incidence of complications in femoral neck fracture treated with cannulated screws. Injury 2014; 45 Suppl 5:S36-9. [PMID: 25528623 DOI: 10.1016/s0020-1383(14)70019-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Osteosynthesis of femoral neck fractures is particularly indicated in patients aged under 60 years. A prolonged interval between the fracture and surgical fixation has been associated with avascular necrosis (AVN) of the femoral head. The primary objective of this study was to evaluate the association between the time to surgery and the development of complications in patients with femoral neck fractures. METHODS Patients with displaced fractures of the femoral neck (Garden III or IV) who underwent fixation with three cannulated screws in the inverted triangle configuration from January 2009 to December 2010 were evaluated retrospectively for the development of orthopaedic complications. Patients were divided into two groups according to the time to surgery (within 7 days or more than 7 days). Complication rates were compared between the two groups. Regression analyses were performed to assess the risk factors for complications. RESULTS Thirty-one patients were included in the study; the duration of follow-up ranged from 24 to 50 months. The time from fracture to surgery ranged from 3 to 18 days. Fifteen patients underwent surgery within 7 days, and 16 patients underwent surgery after 7 days. There were four cases of femoral head necrosis. One patient had an associated infection; one patient experienced non-union, and another demonstrated osteosynthesis failure. There were no statistically significant differences in the overall rate of complications between the groups (p = 0.999). None of the preoperative parameters or fracture characteristics were predictive factors for complications. The only factor associated with the development of complications was inadequate fracture reduction in the anteroposterior (AP) view (odds ratio [OR] = 35.50, 95% confidence interval [CI] = 2.56 to 548.36, p = 0.008). CONCLUSIONS The interval between the occurrence of the injury and surgical fixation is not associated with the development of complications in fractures of the femoral neck. Inadequate fracture reduction in the AP view is a predictive factor for complications in these fractures.
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Affiliation(s)
- Thiego Pedro Freitas Araujo
- Department of Orthopaedics and Traumatology, University of São Paulo, Brazil; Rua Ovidio Pires de Campos, São Paulo - SP, Brazil.
| | - Tales Mollica Guimaraes
- Department of Orthopaedics and Traumatology, University of São Paulo, Brazil; Rua Ovidio Pires de Campos, São Paulo - SP, Brazil
| | - Fernando Brandao Andrade-Silva
- Department of Orthopaedics and Traumatology, University of São Paulo, Brazil; Rua Ovidio Pires de Campos, São Paulo - SP, Brazil
| | - Kodi Edson Kojima
- Department of Orthopaedics and Traumatology, University of São Paulo, Brazil; Rua Ovidio Pires de Campos, São Paulo - SP, Brazil
| | - Jorge Dos Santos Silva
- Department of Orthopaedics and Traumatology, University of São Paulo, Brazil; Rua Ovidio Pires de Campos, São Paulo - SP, Brazil
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Tsang STJ, Aitken SA, Golay SK, Silverwood RK, Biant LC. When does hip fracture surgery fail? Injury 2014; 45:1059-65. [PMID: 24794618 DOI: 10.1016/j.injury.2014.03.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 03/25/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Hip fractures remain the most common orthopaedic injury requiring hospital admission. Failed surgery for any cause carries a higher morbidity, mortality, and healthcare-related cost. The aims of this study were to determine risk factors for surgical complications of hip fracture surgery, when they occurred and their effect on mortality. PATIENTS AND METHODS From a prospectively collected consecutive database of 795 hip fractures admitted between July 2007 and June 2008, all surgical and non-surgical complications were identified as well as re-operation for any cause and mortality in the 4 years since surgery. RESULTS Fifty-five (6.9%) patients were found to have developed a surgical complication requiring further intervention. Risk factors included younger age, smoking and cannulated screw fixation. Cannulated screw fixation was associated with a 30.9% rate of re-operation. Post-operative medical complication occurred in 21.8%. It was associated with a 78.5% mortality at 4 years with a median time to mortality of 58 days (95% CI 0-120 days). CONCLUSIONS Mechanical failure was the most common reason for cannulated screw re-operation. Hip hemiarthroplasty most commonly failed by infection. Inter-trochanteric and sub-trochanteric fracture fixation had very low failure rates. Post-operative medical complications, but not surgical complications, were associated with a higher mortality rate.
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Affiliation(s)
- S T J Tsang
- Department of Trauma and Orthopaedic Surgery, Royal Infirmary Edinburgh, UK.
| | - S A Aitken
- Department of Trauma and Orthopaedic Surgery, Royal Infirmary Edinburgh, UK
| | - S K Golay
- Department of Trauma and Orthopaedic Surgery, Royal Infirmary Edinburgh, UK
| | - R K Silverwood
- Department of Trauma and Orthopaedic Surgery, Royal Infirmary Edinburgh, UK
| | - L C Biant
- Department of Trauma and Orthopaedic Surgery, Royal Infirmary Edinburgh, UK
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Gardner S, Weaver MJ, Jerabek S, Rodriguez E, Vrahas M, Harris M. Predictors of early failure in young patients with displaced femoral neck fractures. J Orthop 2014; 12:75-80. [PMID: 25972697 DOI: 10.1016/j.jor.2014.01.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 01/05/2014] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION This study compares early failure rates of sliding hip screw (SHS) and cannulated screw (CS) constructs in young patients. METHODS Patients <60 years of age, with displaced femoral neck fractures treated with CS or SHS fixation were included. Primary outcome was failure within 6 months. RESULTS One patient (3%) with SHS fixation and 6 patients (21%) with CS fixation failed within 6 months (P = 0.04). Regression analysis demonstrated type of fixation (P = 0.005) and reduction quality (P = 0.04) are independent predictors of early failure. CONCLUSIONS SHS constructs demonstrate a significantly lower short-term failure rate than CS constructs.
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Affiliation(s)
- Stephen Gardner
- Kerlan-Jobe Orthopaedic Foundation, Kerlan-Jobe Orthopaedic Clinic, Los Angeles, CA, USA
| | - Michael J Weaver
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Seth Jerabek
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Edward Rodriguez
- Department of Orthopedics, Beth Isreal Deaconess Hospital, Boston, MA, USA
| | - Mark Vrahas
- Department of Orthopaedics, Massachusetts General Hospital, Boston, MA, USA
| | - Mitchel Harris
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
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Osteosynthesis of unstable intracapsular femoral neck fracture by dynamic locking plate or screw fixation: early results. J Orthop Trauma 2014; 28:70-6. [PMID: 23860134 DOI: 10.1097/bot.0b013e3182a225fa] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The purpose of this study was to compare the postoperative radiologic and clinical outcomes of telescopic femur neck screws and small locking plate device (Targon FN) (group 1) with multiple cancellous screws (group 2) for displaced intracapsular femoral neck fractures. DESIGN Comparison of a prospective collected data to a historical control group (retrospective). SETTING One community teaching hospital. PATIENTS Seventy-eight patients (group 1, 31; group 2, 47) underwent reduction and internal fixation of displaced intracapsular femoral neck fractures with either Targon FN device or multiple cancellous screws from March 2000 to July 2010. Their mean age was 53.7 years (SD: 16.4), and the mean follow-up period was 28.6 months. MAIN OUTCOME MEASURES Treatment failure was considered to be either a nonunion, osteonecrosis, or revision surgery of any type. Treatment was regarded as successful in patients who did not show failure and had at least 1-year follow-up. RESULTS One patient in group 1 (3.2%) and 22 (46.8%) in group 2 had a nonunion (P = 0.0001). Four (12.9%) group 1 patients and 16 (34.0%) group 2 patients underwent revision surgery (P = 0.036). Four (12.9%) patients in group 1 and 4 (8.5%) group 2 patients had osteonecrosis of the femoral head (P = 0.531). Multivariate logistic regression showed that internal fixation by the fixed-angle fixation device decreased the odds ratio for overall complication by a factor of 0.23, for example, by 77% (P = 0.018). CONCLUSIONS Performing internal fixation by a fixed-angle fixation device decreased nonunion rates and revision rates. It did not affect the rate of osteonecrosis. LEVEL OF EVIDENCE Therapeutic level III. See instructions for authors for a complete description of levels of evidence.
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Gotfried Y, Kovalenko S, Fuchs D. Nonanatomical reduction of displaced subcapital femoral fractures (Gotfried reduction). J Orthop Trauma 2013; 27:e254-9. [PMID: 23481921 DOI: 10.1097/bot.0b013e31828f8ffc] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The purpose of this presentation is to describe the Gotfried (nonanatomical) reduction technique of unstable subcapital femoral fractures. In addition, to report, retrospectively, on the radiological outcomes of displaced subcapital femoral fractures reduced with the Gotfried reduction method. The technique involves creation of a positive buttress between the proximal and distal fracture parts to prevent future reduction deterioration once fracture line bone resorption takes place as well as reduction in valgus. Presented are unstable Garden 3/4 cases, 4 cases stabilized with the Physiological Hip Nail, and 1 with the PC.C.P plate. No radiological signs of fracture redisplacement, nonunion, or AVN were detected at a follow-up minimum of 12 months. Results of this technique are encouraging. Larger scale and multiple studies are needed to confirm the value of this new reduction method.
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Affiliation(s)
- Yechiel Gotfried
- Department of Orthopedic Surgery, Bnai Zion Medical Center, Haifa, Israel
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Watson A, Zhang Y, Beattie S, Page RS. Prospective randomized controlled trial comparing dynamic hip screw and screw fixation for undisplaced subcapital hip fractures. ANZ J Surg 2012; 83:679-83. [PMID: 22998439 DOI: 10.1111/j.1445-2197.2012.06256.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Neck of femur fractures (NOFFs) are a common cause of morbidity and mortality in our community. Minimally displaced intracapsular fractures are treated with internal fixation by a two-hole dynamic hip screw (DHS) or three partially threaded cancellous screws. Data to support the superiority of one are limited. This prospective randomized controlled trial compares outcomes with these two fixation methods. METHODS We prospectively recruited patients over 50 years, with an acute fracture subcapital NOFF, who walked and lived independently, and were cognitively intact. They were randomized into DHS or cancellous screw groups and followed up for 2 years (overall 75.9%). Outcomes of mortality, revision, loss of fixation, avascular necrosis, surgical complications, WOMAC, Harris hip score and SF-12 were measured. RESULTS We recruited 62 patients (31 DHS, 29 cancellous screws, 2 failed consent). Six deaths (19.3%) were seen in each group. A total of 3.2% of DHS (1 out of 31) and 10.3% (3 out of 29) of cancellous screw patients required re-operation (P = 0.272). There was no statistical significant difference in patient satisfaction, quality of life (QoL), radiological union or osteonecrosis. There are trends towards better functional scores and QoL in cancellous screws, particularly at 1 year (P = 0.0061), but with a higher re-operation rate. There was a combined mortality and transition to institutional care of 40.0% (24 out of 60) at 2 years. CONCLUSIONS This study found no difference in outcomes between DHS and cancellous screws in the treatment of subcapital NOFFs in a fit, independent population, but we found a high level of physical decline in previously fit, independently ambulating patients. A large, multicentre trial will be required to differentiate between these two fixation methods.
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Affiliation(s)
- Adam Watson
- Barwon Orthopaedic Research Unit, The Geelong Hospital, Barwon Health, Geelong, Victoria, Australia.
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Marmor M, Nystuen C, Ehemer N, McClellan RT, Matityahu A. Accuracy of in situ neck-shaft angle and shortening measurements of the anatomically reduced, varus malreduced and shortened proximal femur: can we believe what we see on the postoperative films? Injury 2012; 43:846-9. [PMID: 22040694 DOI: 10.1016/j.injury.2011.10.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Revised: 10/07/2011] [Accepted: 10/09/2011] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Measuring the neck-shaft angle (NSA) and amount of shortening of the femoral neck on the anterior to posterior (AP) X-ray is important when treating proximal femur fractures. To compensate for proximal femoral external rotation, the X-rays need to be taken with the leg internally rotated, an act that cannot always be performed or verified. This study aims to define the utility of in situ AP X-ray in NSA and shortening measurements. METHODS Computed tomography (CT) scans of 50 patients undergoing abdominal CT scans were assessed for the in situ rotation of the femoral neck relative to the AP beam. Three proximal femur fracture Sawbones models were made and AP X-rays of the models were taken with changing proximal femur rotation. NSA and shortening were measured on all X-rays. RESULTS In situ femoral neck rotation averaged 25.4±10.6° of external rotation (range, 0.9-51.8°, 80% of measurements less than 35°). NSA measurements varied less than 5° with less than 35° of rotation in all models, and were always greater than the true value. Femoral neck vertical length (VL) measurement was independent of proximal femur rotation whereas the horizontal length component was found to be highly dependent on the same. CONCLUSIONS NSA measured on AP X-ray will be accurate to within 5° in 80% of patients with the hip left in situ and in 100% of the patients if the hip is internally rotated 15°. Measurement of significant varus or loss of VL of the femoral neck can be considered accurate regardless of leg rotation at the time of X-rays being taken.
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Affiliation(s)
- Meir Marmor
- Orthopaedic Trauma Institute, San Francisco General Hospital, University of California, San Francisco, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110, USA.
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Sen RK, Tripathy SK, Goyal T, Aggarwal S, Tahasildar N, Singh D, Singh AK. Osteosynthesis of femoral-neck nonunion with angle blade plate and autogenous fibular graft. INTERNATIONAL ORTHOPAEDICS 2012; 36:827-32. [PMID: 21881882 PMCID: PMC3311820 DOI: 10.1007/s00264-011-1344-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2011] [Accepted: 08/15/2011] [Indexed: 02/08/2023]
Abstract
PURPOSE Revision internal fixation for femoral-neck nonunion is a challenging procedure. Treatment options are osteotomy, osteosynthesis using various implants and grafting techniques (muscle pedicle, vascularised or nonvascularised fibular graft) or arthroplasty. The objective of this article is to report the outcome of revision internal fixation using an angle blade plate and autogenous fibular graft in symptomatic aseptic femoral-neck nonunion. METHODS Twenty-two patients who had been treated previously with cannulated screws or dynamic hip screw for femoral-neck fracture and progressed to nonunion were treated with revision internal fixation using an angle blade plate and autogenous nonvascularised fibular graft. Mean patient age was 38 (range 21-52) years, with average duration between injury and revision surgery 11.2m (range 8-16 months). RESULTS Other than one nonunion, we achieved union in all patients (21 patients, 91%) after an average period of 4.4 months. The functional outcome after 3.2 years as per scoring system given by Nagi et al.. showed excellent results in four, good in ten, fair in six and poor in two patients. Patients with poor results included one with nonunion and other with avascular necrosis with collapse of the femoral head. Average limb shortening was 1.5 cm, and mean femoral-neck-shaft angle was 116°. There was no instance of fibular graft fracture, slippage or implant cut-through. CONCLUSION Angle blade plate provides rigid stability and offloads any shearing force over the fibular graft when used for revision internal fixation in aseptic femoral-neck nonunion. Thus, the fibular graft only serves the purpose of osteogenesis and stimulates the surrounding host cells to promote healing at the nonunion site. We recommend the angle blade plate and autogenous fibular graft as a viable option for hip-joint salvage in revision internal fixation of aseptic femoral-neck nonunion.
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Affiliation(s)
- Ramesh Kumar Sen
- Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012 India
| | - Sujit Kumar Tripathy
- Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012 India
- Department of Orthopaedics, Friarage Hospital, Northallerton, UK DL6 1JG
| | - Tarun Goyal
- Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012 India
| | - Sameer Aggarwal
- Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012 India
| | - Naveen Tahasildar
- Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012 India
| | - Daljit Singh
- Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012 India
| | - Amit Kumar Singh
- Department of Orthopaedics, Govt. Medical College and Hospital, Chandigarh, India
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Abstract
OBJECTIVE To evaluate the outcomes of displaced intracapsular femoral neck fractures treated with a cephalomedullary device. DESIGN Retrospective study. SETTING Level I trauma center. PATIENTS Between 2002 and 2008, 18 patients with displaced intracapsular femoral neck fractures were treated at our Level I trauma center with a cephalomedullary nail. There were 12 males and six females. Six patients were younger than 60 years of age with a mean age of 63 years (range, 40-88 years). Thirteen fractures were midcervical (Orthopaedic Trauma Association [OTA] 31-B2.2 and B2.3), and five fractures were subcapital (OTA 31-B3). Patients with basicervical fractures (OTA 31-B2.1) and nondisplaced subcapital fractures (OTA 31-B1) were excluded. INTERVENTION All patients underwent cephalomedullary nail fixation of their femoral neck fractures under the supervision of fellowship-trained orthopaedic trauma surgeons. MAIN OUTCOME MEASUREMENTS Postoperative radiographs were evaluated for fracture reduction quality. Clinical follow-up was available on 13 patients with a minimum of 12 months (range, 12-25 months). A radiographic and chart review was done to identify complications and outcomes. RESULTS Seven of eight fractures that healed were anatomically reduced. No failures occurred in the six patients younger than 60 years. Fixation failed in five of 13 fractures (38.4%) with varus collapse as the typical failure mode. The mean time to failure in these cases was 3.8 months (range, 1-7 months). Overall, the failure rate for the subcapital fractures was 100% (three of three) and for midcervical 20% (two of 10) with all failures being in patients older than 60 years (71.4%). Osteonecrosis without fixation failure or cutout occurred in one case. CONCLUSION Cephalomedullary nail fixation of displaced intracapsular femoral neck fractures demonstrated mixed results. For younger patients with midcervical fractures that were well reduced, the fixation performed well. Displaced subcapital fractures in patients older than 60 years demonstrated a 100% failure rate. As a result, we cannot advocate cephalomedullary fixation for displaced intracapsular femoral neck fractures in patients older than 60 years, although in younger patients, these implants may provide an alternative to side-plate based fixation devices.
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Duckworth AD, Bennet SJ, Aderinto J, Keating JF. Fixation of intracapsular fractures of the femoral neck in young patients. ACTA ACUST UNITED AC 2011; 93:811-6. [DOI: 10.1302/0301-620x.93b6.26432] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The aim of this study was to determine the comorbid risk factors for failure in young patients who undergo fixation of a displaced fracture of the femoral neck. We identified from a prospective database all such patients ≤ 60 years of age treated with reduction and internal fixation. The main outcome measures were union, failure of fixation, nonunion and the development of avascular necrosis. There were 122 patients in the study. Union occurred in 83 patients (68%) at a mean follow-up of 58 months (18 to 155). Complications occurred in 39 patients (32%) at a mean of 11 months (0.5 to 39). The rate of nonunion was 7.4% (n = 9) and of avascular necrosis was 11.5% (n = 14). Failures were more common in patients over 40 years of age (p = 0.03). Univariate analysis identified that delay in time to fixation (> 24 hours), alcohol excess and pre-existing renal, liver or respiratory disease were all predictive of failure (all p < 0.05). Of these, alcohol excess, renal disease and respiratory disease were most predictive of failure on multivariate analysis. Younger patients with fractures of the femoral neck should be carefully evaluated for comorbidities that increase the risk of failure after reduction and fixation. In patients with a history of alcohol abuse, renal or respiratory disease, arthroplasty should be considered as an alternative treatment.
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Affiliation(s)
- A. D. Duckworth
- Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SU, UK
| | - S. J. Bennet
- Gloucestershire Royal Hospital, 23 Cotham Road, Bristol BS6 6DJ, UK
| | - J. Aderinto
- Department of Orthopaedics and Trauma, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK
| | - J. F. Keating
- Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SU, UK
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Elgafy H, Ebraheim NA, Bach HG. Revision internal fixation and nonvascular fibular graft for femoral neck nonunion. THE JOURNAL OF TRAUMA 2011; 70:169-73. [PMID: 20693917 DOI: 10.1097/ta.0b013e3181e5108b] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The rates of nonunion after internal fixation for femoral neck fractures have been reported to range from 0% to 59%. Existing treatment options are osteotomy (with or without graft), osteosynthesis using various implants and grafting techniques (muscle pedicle, vascularized, and nonvascularized fibula), or arthroplasty. The objective of this study was to assess the outcome results of revision internal fixation and nonvascular fibular bone grafting for symptomatic aseptic femoral neck nonunion. METHODS This is a retrospective case series study involving 17 patients with symptomatic femoral neck nonunion that were treated with revision internal fixation and fibular bone graft. The inclusion criteria were aseptic symptomatic femoral neck nonunion with no or minimal varus alignment. There were eight men and nine women. The average age was 46 years (range, 24-58 years). Thirteen patients had autogenous fibular bone graft, and six patients had fibular allograft. RESULTS Of the 13 patients who had autogenous nonvascularized fibular bone grafts, four remained in nonunion. Fibular autograft had a 69.2% success rate with the mean time to union 4.8 months. Four of the six patients who had fibular allografts remained in nonunion. Fibular allograft had a 33.3% success rate with the mean time to union 13.3 months. CONCLUSION This study showed that revision internal fixation and fibular autograft have resulted into a better and faster union rate than fibular allografts.
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Affiliation(s)
- Hossein Elgafy
- Department of Orthopaedic Surgery, University of Toledo, Toledo, Ohio 43614-5807, USA.
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Norouzi M, Alami-harandi B, Naderi MN. Treatment of nonunion of femoral neck fracture by valgus osteotomy in 33 cases. Eur J Trauma Emerg Surg 2009; 35:475. [DOI: 10.1007/s00068-009-8186-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2008] [Accepted: 01/11/2009] [Indexed: 10/21/2022]
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Dai Z, Li Y, Jiang D. Meta-analysis comparing arthroplasty with internal fixation for displaced femoral neck fracture in the elderly. J Surg Res 2009; 165:68-74. [PMID: 19552922 DOI: 10.1016/j.jss.2009.03.029] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2009] [Revised: 03/07/2009] [Accepted: 03/16/2009] [Indexed: 12/17/2022]
Abstract
BACKGROUND The treatment of displaced femoral neck fracture includes internal fixation and arthroplasty. However, which is the best surgical treatment for the elderly patient with displaced femoral neck fractures has been controversial. Our objective was to compare the clinical effects of internal fixation with that of arthroplasty for displaced femoral neck fracture in the elderly (≥60 y of age). MATERIALS AND METHODS We searched for all randomized controlled trials of hip arthroplasty versus internal fixation for displaced femoral neck fractures in the elderly by electronically searching PUBMED (1966 to December, 2008), MEDILINE (1966 to December, 2008) and manually searching grey literatures. The quality of the trials was assessed and meta-analyses were conducted using the Cochrane Collaboration's RevMan 4.2 software. RESULTS Nineteen published randomized controlled trials involving a total of 3505 patients were suitable for inclusion in the review. The combined results of meta-analyses showed no significant difference in mortality at 1 y postoperatively between the two methods. However, compared with internal fixation, arthroplasty could reduce the rate of reoperations and the major method-related complications. CONCLUSIONS Compared with internal fixation, arthroplasty can not only reduce the surgical revision, but also decrease the incidence of complications, and does not increase mortality. The present meta-analysis shows that there is an evidence base to support arthroplasty as a primary treatment for displaced femoral neck fractures in the elderly.
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Affiliation(s)
- Zhenyu Dai
- Department of Orthopedics, the First Affiliated Hospital, Chongqing Medical University, Chongqing, China
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Liporace F, Gaines R, Collinge C, Haidukewych GJ. Results of internal fixation of Pauwels type-3 vertical femoral neck fractures. J Bone Joint Surg Am 2008; 90:1654-9. [PMID: 18676894 DOI: 10.2106/jbjs.g.01353] [Citation(s) in RCA: 197] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND It has been postulated that femoral neck fractures with a more vertical fracture line (i.e., a high Pauwels angle) may experience more shear forces and therefore may be predisposed to nonunion or loss of fixation. Although there is controversy regarding which fixation method is ideal, we are aware of no large clinical series in which the treatment outcomes of these fractures were evaluated. The purpose of this multicenter study was to evaluate a large consecutive series of high shear angle (>70 degrees) femoral neck fractures to learn more about the outcomes, complications, and performance of various internal fixation strategies. METHODS Between January 1993 and January 2005, seventy-six Pauwels type-3 (Orthopaedic Trauma Association [OTA] type-31B2.3) femoral neck fractures were treated in seventy-five patients with a mean age of forty-two years. Fourteen patients were lost to follow-up. Sixty-two fractures in sixty-one patients were followed to union or revision surgery, with a mean duration of follow-up of twenty-four months. Thirty-seven fractures were treated with cannulated screws and twenty-five, with a fixed-angle device. The reduction quality, accuracy of implant placement, time to surgery, influence of capsular decompression, and rates of nonunion and osteonecrosis were evaluated. RESULTS Fifty-nine (95%) of the fractures had good-to-excellent reduction, and three had a fair reduction. There was a nonunion of eight (14%) of the fifty-nine fractures with a good-to-excellent reduction and two of the three with a fair reduction. There was a septic nonunion of one fracture treated with a dynamic hip screw. There was an aseptic nonunion of seven (19%) of the thirty-seven fractures treated with screw fixation alone as compared with two (8%) of the twenty-five fractures treated with a fixed-angle device. Osteonecrosis occurred after treatment of seven (11%) of the sixty-two fractures. CONCLUSIONS Despite timely, excellent reduction and accurate implant placement in the vast majority of cases, the nonunion rate was 19% for fractures treated with cannulated screws alone and 8% for those treated with a fixed-angle device. Although these failure rates are not significantly different, we believe that this study documents the challenging nature of this fracture pattern and the ideal fixation device remains undefined.
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Affiliation(s)
- Frank Liporace
- Investigation performed at North Jersey Orthopedic Institute, Newark, New Jersey, USA
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Molnar RB, Routt MLC. Open reduction of intracapsular hip fractures using a modified Smith-Petersen surgical exposure. J Orthop Trauma 2007; 21:490-4. [PMID: 17762484 DOI: 10.1097/bot.0b013e31804a7f7f] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The Smith-Petersen or modified direct anterior hip surgical exposures have not previously been described for open reduction of femoral neck fractures. This technique of reduction provides a direct approach to the femoral neck and hip joint. Displaced fractures of the femoral neck can easily be reduced through this approach, local osseus defects resulting from impaction can be supported with bone graft, and fracture fixation is then placed through a separate lateral exposure or through small stab incisions. The technique of reduction is presented.
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Affiliation(s)
- Robert B Molnar
- Harborview Medical Center, Department of Orthopaedic Surgery, Seattle, Washington 98104, USA.
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Tötterman A, Walløe A, Nordsletten L. Interpreting preoperative radiographs in displaced femoral neck fractures: observer variability in evaluating signs of poor outcome. Arch Orthop Trauma Surg 2007; 127:185-9. [PMID: 17221231 DOI: 10.1007/s00402-006-0276-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2005] [Indexed: 02/09/2023]
Abstract
OBJECTIVE To evaluate the reproducibility of four preoperative radiographic signs thought to be associated with negative prognosis in dislocated femoral neck fractures when treated with internal fixation. SETTING University Hospital. DESIGN Standard hip radiographs of ten patients with displaced subcapital femoral neck fractures were studied by five orthopaedic surgeons. The radiographs were studied twice; the second time on average 3 months after the first reading. Inter- and intra-observer reliability of four radiological parameters was estimated. RESULTS Poor intra- and inter-observer reproducibility of all four signs tested was observed. CONCLUSIONS The decision to treat an intracapsular femoral neck fracture with either prosthesis or internal fixation has to be based on other variables than the preoperative radiographic signs evaluated in this study.
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Affiliation(s)
- A Tötterman
- Orthopaedic Centre, Ullevål University Hospital, Kirkev 166, 0407, Oslo, Norway.
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Heetveld MJ, Raaymakers ELFB, Luitse JSK, Gouma DJ. Rating of internal fixation and clinical outcome in displaced femoral neck fractures: a prospective multicenter study. Clin Orthop Relat Res 2007; 454:207-13. [PMID: 17031315 DOI: 10.1097/01.blo.0000238867.15228.8d] [Citation(s) in RCA: 19] [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
The influence of precise surgical technique on the clinical outcome of internal fixation for displaced femoral neck fractures is an under-reported and potential confounding factor in randomized studies involving internal fixation as a treatment modality. Two experienced surgeons blindly rated internal fixation techniques on the perioperative radiographs of 102 patients selected for internal fixation in a prospective multicenter 2-year followup study. Overall technical, fracture reduction, and implant positioning ratings were given according to instruction. One or both raters assigned an inadequate overall rating in 25% of patients. There was a correlation with 2-year clinical internal fixation failure for overall technique and fracture reduction rating. Implant positioning did not correlate with 2-year internal fixation failure. Correlation increased if both raters agreed on inadequate technique. One inadequate rating indicated a problem could arise, whereas two inadequate ratings strengthened this problem likelihood. Adjudication of technique by independent rater(s) is useful, may have clinical implications, and should be performed routinely in future studies involving internal fixation in patients with displaced femoral neck fractures.
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Affiliation(s)
- M J Heetveld
- Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
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Affiliation(s)
- Robert Probe
- Department of Orthopaedic Surgery, Scott and White Memorial Hospital and Clinic, Scott, Sherwood and Brindley Foundation, The Texas A&M University System Health Science Center College of Medicine, Temple, TX 76508, USA
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Helbig L, Werner M, Schneider S, Simank HG. [Garden I femoral neck fractures: conservative vs operative therapy]. DER ORTHOPADE 2006; 34:1040-5. [PMID: 16078057 DOI: 10.1007/s00132-005-0855-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Treatment recommendations vary for Garden I fractures of the proximal femur. The aim of our retrospective study was to determine the results of functional treatment of these injuries. MATERIAL AND METHODS A total of 54 consecutive patients were enrolled, and their data (age, comorbidities, treatment, complications, etc.) were ascertained and stored in a database. Initial treatment consisted in early mobilization and weight bearing in all patients. RESULTS In 24 cases (44%) no complications at all were observed in the course of conservative treatment. In 28 cases (52%) surgical treatment was necessary due to early fracture dislocation. Analysis of the X-ray images showed that in 9 of these 28 cases the functional treatment had not been clearly indicated, i.e., incomplete impaction of the fragments. When these patients are excluded the success rate of conservative treatment was 53%, as two additional late complications occurred and were treated surgically (1x AVN, 1x nonunion). With reference to the survival rate, score, and patient satisfaction, there was no difference between conservative and operative treatment (p=0.478). The risk of a secondary dislocation increases with the number of risk factors (p=0.008). DISCUSSION An attempt at functional treatment with close X-ray monitoring is appropriate in these fractures, since this makes it possible to avoid surgery in about half of the patients while achieving functional results comparable to those yielded by surgery.
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Affiliation(s)
- L Helbig
- Stiftung Orthopädische Universitätsklinik, Heidelberg
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Chen WC, Yu SW, Tseng IC, Su JY, Tu YK, Chen WJ. Treatment of Undisplaced Femoral Neck Fractures in the Elderly. ACTA ACUST UNITED AC 2005; 58:1035-9; discussion 1039. [PMID: 15920421 DOI: 10.1097/01.ta.0000169292.83048.17] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND While the treatment for displaced femoral neck fractures in the elderly (Garden types III and IV) is quite clear, the procedure for impacted or undisplaced femoral neck fractures (Garden types I and II) is still a subject of controversy. METHODS Thirty-seven (all >80 years old) patients with undisplaced femoral neck fractures were treated with osteosynthesis by cannulated screws fixation. The clinical outcomes were followed up retrospectively for at least two years. RESULTS The overall union rate was 94.59% (35 patients) at 6 months after primary internal fixation. The overall success rate was 83.78% (31 patients), and the overall failure rate was 16.22% (6 patients). CONCLUSIONS Osteosynthesis with cannulated screws fixation is a simple, safe, economical, and reasonably effective procedure for the treatment of undisplaced femoral neck fractures in patients older than 80 years.
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Affiliation(s)
- Wei-Chih Chen
- Division of Trauma Orthopedics, Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Linkuo, Taiwan, Republic of China
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Heetveld MJ, Raaymakers ELFB, van Walsum ADP, Barei DP, Steller EP. Observer assessment of femoral neck radiographs after reduction and dynamic hip screw fixation. Arch Orthop Trauma Surg 2005; 125:160-5. [PMID: 15742193 DOI: 10.1007/s00402-004-0780-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2004] [Indexed: 11/29/2022]
Abstract
INTRODUCTION It is not known how the described methods of reduction and dynamic hip screw (DHS) fixation of displaced intracapsular femoral neck fractures translate into proper assessment of the postoperative radiographs. At teaching or evaluation sessions in daily practice, frequent discussion arises about postoperative technical assessment. The assessment of correct reduction and DHS fixation using the described methods in the literature may be subject to differences between observers. The aim of this study was to assess the extent of inter- and intraobserver agreement on technique, based on the methods in the literature, in a simulated daily practice setting. MATERIALS AND METHODS The postoperative anteroposterior (AP) and lateral radiographs of 35 randomly selected patients aged 60-90 years were rated twice, 2 months apart, by six surgical observers from three institutions with similar views on reduction and DHS fixation for this fracture type. The radiographs were of sufficient quality for proper assessment. Criteria for reduction and fixation could be rated as either adequate or inadequate. An adequate rating was assigned if in the observer's opinion, regardless of likely outcome, technical perfection according to the described methods had been achieved. The kappa statistic was calculated as a measure of agreement. RESULTS Fracture reduction on the AP view approached a good kappa value (0.54). Poor to moderate interobserver agreement was found for fracture reduction on the lateral view and aspects of DHS fixation (kappa 0.10-0.36). Intraobserver agreement was good for five out of six observers for reduction and DHS fixation aspects (kappa 0.51-0.81). CONCLUSION During routine practice six surgical observers can nearly agree on adequate fracture reduction on the AP view, but do not agree on adequate reduction on the lateral view and adequate DHS fixation on the postoperative radiographs of displaced intracapsular femoral neck fractures.
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Affiliation(s)
- Martin J Heetveld
- Department of Trauma and General Surgery, Erasmus Medical Center, PO Box 2040, 3000 CA Rotterdam, The Netherlands.
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