Interobserver reliability of classification systems to rate the quality of femoral neck fracture reduction

Contralateral Neck-shaft Angle Lower Than 130° Is Associated With Clinical Failure in Nongeriatric Individuals: Analysis of the National Femoral Neck Fracture Database of 1066 Patients

BACKGROUND

Treatment of femoral neck fractures in patients who are nongeriatric (≤ 60 years) is challenging because of high failure rates. Anatomic parameters influence the biomechanical environment for fracture healing, but their associations with clinical prognosis remains unclear.

QUESTIONS/PURPOSES

(1) Which anatomic parameter that is identifiable on pelvic radiographs shows a statistical correlation with a higher risk of clinical failure defined as nonunion, avascular necrosis (AVN), reoperation, and functional failure (decrease in Harris hip score reaching the minimum clinically important difference) in the screw fixation of femoral neck fractures among nongeriatric patients? (2) How does the influence of anatomic parameters on clinical prognosis manifest: directly or mediated by additional mechanisms?

METHODS

This retrospective, multicenter study used a nationwide database in China. Between January 2014 and December 2020, we evaluated 1066 patients with femoral neck fractures with a median age of 53 years (interquartile range 46 to 56) and median follow-up period of 62 months. Anatomic parameters including femoral neck-shaft angle (NSA), femoral head radius, femoral neck width, femoral offset, acetabular center-edge angle, and acetabular sharp angle were variables of interest. The primary outcome was clinical failure including nonunion, AVN, reoperation, and functional failure (decrease in Harris hip score reaching the minimum clinically important difference). Risk factors for failure were first filtered using the Bayesian information criterion and then assessed with multiple regression adjusting for confounders. The mediation effect was further explored using model-based causal mediation analysis with a quasi-Bayesian Monte Carlo method.

RESULTS

Of all anatomic parameters we assessed, the contralateral NSA was associated with clinical failure, after adjusting for all potential covariates and confounding variables (adjusted odds ratio 0.92 [95% confidence interval 0.89 to 0.95]; p < 0.001). The optimal threshold for the NSA was 130°, with the highest Youden index of 0.27. Patients with an NSA < 130° (41% [441 of 1066]) demonstrated an increased occurrence of nonunion (15% [68 of 441] versus 5% [33 of 625]; p < 0.001), AVN (32% [141 of 441] versus 22% [136 of 625]; p < 0.001), functional failure (25% [110 of 441] versus 15% [93 of 625]), and reoperations (28% [122 of 441] versus 13% [79 of 625]). The impact of an NSA less than 130° on clinical failure was direct and substantially mediated by the type of displaced fracture (mediation proportion: 18.7%).

CONCLUSION

In our study of screw fixations for femoral neck fractures among nongeriatric patients, we identified that a contralateral NSA < 130° correlates with an increased risk of clinical failure including nonunion, AVN, functional failure, and reoperation. The effect is either direct or mediated through displaced fracture types. This is important for surgeons in order to recognize the elevated rate of clinical failure and nature of the challenging biomechanical environment, which should guide them in refining surgical details and selecting appropriate fixation and rehabilitation plans. Approaches to managing these fractures require further validation with large-scale clinical trials.

LEVEL OF EVIDENCE

Level III, prognostic study.

Comparison of femoral neck shortening after femoral neck system and cannulated cancellous screw fixation for displaced femoral neck fractures in young adults

BACKGROUND

The purpose of this study was to compare the outcomes of femoral neck shortening between the femoral neck system (FNS) and the cannulated cancellous screws (CCS) for displaced femoral neck fractures in young adults PATIENTS AND METHODS: In this retrospective analysis, 225 patients aged 18-65 years with displaced femoral neck fracture were divided into two groups according to internal fixation: 135 patients in the FNS group and 90 patients in the CCS group. The length of hospital stay, duration of surgery, intraoperative blood loss, quality of reduction, extent of femoral neck shortening, incidence of femoral neck shortening, femoral neck shortening at each follow-up visit, Harris hip score (HHS), reoperation, and complications were compared between the two groups.

RESULTS

The median follow-up time was 28.2 (26.0, 31.2) months in the FNS group and 30.2 (26.3, 34.7) months in the CCS group. The follow-up time, age, sex distribution, body mass index (BMI), mechanism of injury, injured side, length of hospital stay, time from injury to surgery, and fracture classification were similar between the groups. Duration of surgery was longer in the FNS group (65.0 (55.0, 87.0) min versus 55.0 (50.0, 65.0) min, P<0.001); intraoperative blood loss was greater in the FNS group (50.0 (20.0, 60.0) ml versus 20.0 (10.0, 35.0) ml, P<0.001). Femoral neck shortening was 2.4 (1.0, 4.5) mm in the FNS group versus 0.6 (0.0, 2.6) mm in the CCS group at 1 month postoperatively (P<0.001); 3.7 (1.8, 6.4) mm in the FNS group versus 1.2 (0.6, 3.8) mm in the CCS group at 3 months (P<0.001); 4.1(2.4, 7.7) mm in the FNS group versus 2.3 (1.1, 4.4) mm in the CCS group at 6 months (P<0.001); 4.2 (2.6, 7.7) mm in the FNS group versus 2.6 (1.3, 4.6) mm in the CCS group at 12 months (P<0.001); and 4.5 (2.8, 8.0) mm in the FNS group versus 2.8 (1.5, 4.8) mm in the CCS group at 18 months (P<0.001). The two groups showed no significant differences in HHS, reoperation, and reduction quality.

CONCLUSION

Compared to CCS, FNS is deficient in preventing femoral neck shortening. Future research should focus on improving FNS in terms of preventing femoral neck shortening.

Compressive buttress compared with off-axial screw fixation for vertical femoral neck fractures in young adults: a prospective, randomized controlled trial

BACKGROUND

To compare the clinical outcomes of compressive buttress screw (CBS) fixation, a novel screw fixation strategy, to off-axial screw fixation (off-axial partial threaded cannulated screw, OPTCS) for vertical femoral neck fractures (FNFs) in young adults.

METHODS

A total of 146 adults younger than 55 years old with high-energy Pauwels type III FNFs were randomized to receive CBS fixation or OPTCS fixation. Primary outcomes were complication rates, including fixation failure, fracture nonunion, and avascular necrosis of the femoral head (ANFH) at 24 months after treatment. Fixation loosening, femoral neck shortening and varus collapse, patient function and quality of life using the Harris hip score (HHS), and EuroQol-5 dimensional-5 levels (EQ-5D-5L) questionnaire (including EQ-5D-5L and EQ-VAS) were assessed as secondary outcomes at 24 months.

RESULTS

CBS and OPTCS fixation groups were similar with regard to demographics at baseline. At 24 months, patients in the CBS fixation cohort had a significantly lower rate of fixation failure (10.5% vs. 25.0%, p = 0.041) and fracture nonunion (1.8% vs. 18.3%, p = 0.003) compared with patients who received OPTCS fixation. There was no difference in rate of ANFH (7.0% vs. 11.7%, p = 0.389) between groups. Additionally, patients managed with CBS fixation showed significantly less fixation loosening (19.3% vs. 58.3%, p < 0.001), less severe femoral neck shortening and varus collapse (10.5% vs. 25.0%, p = 0.007), higher HHS (93 vs. 83, p = 0.001) and more excellent grade (68.4% vs. 36.7%, p = 0.008), higher EQ-5D-5L (0.814 vs, 0.581, p < 0.001) and EQ-VAS (85 vs. 80, p = 0.002).

CONCLUSION

CBS screw fixation confers significantly lower complication rate in addition to higher functional and quality of life outcomes for young adults with high-energy FNF compared with OPTCS fixation.

TRIAL REGISTRATION

This prospective, randomized controlled trial was approved by the institutional review board of our center, Ethics Committee of Shanghai sixth people's Hospital, and registered at www.chictr.org.cn (Approval Number: ChiCTR1900026283; Registered 29 September 2019-Retrospectively registered, https://www.chictr.org.cn/showproj.html?proj=43164 ).

What is the Fate of Undisplaced Femoral Neck Fractures Treated With Cannulated Screws?

BACKGROUND

We aimed to report implant survival in Garden type I and II femoral neck fractures treated with cannulated screws in elderly patients.

METHODS

We retrospectively studied 232 consecutive unilateral Garden I and II patients (232 fractures) treated with cannulated screws. Mean age was 81 years (range, 65 to 100), and a body mass index of 25 (range, 15.8 to 38.3). No between-group differences were found in demographic variables and/or baseline measurements (P > .05). Mean follow-up was 36 months (range, 1 to 171). Two observers measured baseline radiographic variables with good-to-excellent interobserver reliability. The posterior tilt angle, measured on a cross-table lateral x-ray, was used to classify the cohort into <20° (n = 183) and ≥20° (n = 49). The cumulative incidence with competing risk analysis was used to predict association between posterior tilt and subsequent conversion to arthroplasty. Patient survival was calculated with the Kaplan-Meier estimate.

RESULTS

Implant survival was 86.3% (95% confidence interval (CI) 80 to 90) at 12 months and 77.3% (95% CI 64 to 86) at 70 months. The 12-month cumulative incidence failure was 12.6% (95% CI 8 to 17). After controlling for confounders, posterior tilt ≥20° had higher risk of subsequent arthroplasty when compared to posterior tilt <20° (38.8 [95% CI 25 to 52] versus 5% [95% CI 2.8 to 9], subhazard ratio 8.3, 95% CI 3.8 to 18), without any other radiologic or demographic factor being associated with failure. Patient survival was 88.2% (95% CI 83 to 91.7) at 12 months, 79.5% (95% CI 73 to 84) at 24 months, and 57% (95% CI 48 to 65) at 70 months.

CONCLUSION

Cannulated screws were a reliable treatment for Garden I and II fractures, except when there was posterior tilt ≥20°, where arthroplasty should be considered.

Surgical management of neck of femur fractures in patients younger than sixty-five years: a comparative study of three fixation methods

PURPOSE

Several surgical implants have been used for the treatment of neck of femur fracture (NOF) in younger patients such as dynamic hip screw (DHS) and cannulated compression screw. However, the superiority of one or another osteosynthesis device remains a matter of debate. The aim of this work is to evaluate and compare three fixation modalities: Cannulated Hip Screws (CHS), DHS and DHS associated to anti-rotating screw for surgical treatment of femoral neck fracture in young adults.

METHODS

It is a retrospective comparative study of three series of NOF fractures treated surgically over a period of ten years; including young adult patients (age > 18 years and < 65 years) treated conservatively using closed or open reduction and internal fixation. All types of NOF fractures according to Garden classification were included. Pathological, basi-cervical fractures and fractures on previously operated hips were excluded. The minimum follow-up recommended was two years. Clinical evaluation was based on the Postel Merle d'Aubigné score (PMA), the visual analogue scale (VAS), the Parker score, and the Hip Disability and Osteoarthritis Outcome Score (HOOS score). Reduction quality was assessed on X-rays.

RESULTS

Our series included 72 patients that were divided in three groups: Group A: Fixation using cannulated hip screws (33 patients). Group B: Fixation using DHS only (21 patients). Group C: Fixation using DHS associated to anti-rotation screw (18 patients). The patients of group A had better PMA and VAS scores, but there was no statistically significant difference. However, a significant difference (p=0.001) was found for the HOOS score. The fractures treated with DHS associated with anti-rotating screws, had the highest loss of reduction in the vertical axis (Yp) with the highest femoral head collapse (Zp) values. Group A had the lowest loss of reduction in the horizontal axis (Xp). There was no significant difference between the three methods of osteosynthesis in terms of loss of correction though.

CONCLUSION

We found comparable results in terms of healing and complication rates and loss of reduction for the three groups with no significant difference. However, the HOOS score was significantly better in the cannulated hip screw group.

Validation of a proposed radiographic bone defect classification system

OBJECTIVES

To clinically validate a recently proposed classification scheme of post-traumatic bone defects.

METHODS AND MATERIALS

Open fractures were classified utilising a newly introduced classification system. This classification system is based on plain radiographs, assessing the extent and local geometry of bone loss, including: D1 - Incomplete Defects; D2 - Minor/Sub-Critical (Complete) Defects (<2 cm); and D3 - Segmental/Critical Sized Defects (≥2 cm). Reliability was assessed among six independent assessors (three trauma orthopaedic surgeons and three orthopaedic training surgeons) using Fleiss' kappa tests. 43 open fractures from a tertiary referral trauma centre and their radiographic series were analysed.

RESULTS

Interobserver reliability testing demonstrated the proposed classification system had substantial agreement between the 6 observers, κ = 0.623 (z = 33.8), p < 0.001. Intraobserver variability showed a range of substantial to almost perfect agreement of each observer following a three-week interval between repeat assessments, κ range 0.69-0.914, p < 0.001.

CONCLUSIONS

In this representative validation cohort there was substantial agreement between observers when assessing a diverse range of bone defects following long bone open trauma, with highly reproducible assessments by both orthopaedic surgeons and trainee orthopaedic surgeons alike on an internal level. The classification scheme is based on conventional orthogonal radiographs and requires no sophisticated technology, and is therefore pragmatic and applicable to secondary, tertiary and quaternary levels of care for trauma patients.

LEVEL OF EVIDENCE

III.

Comparison of femoral neck system to multiple cancellous screws and dynamic hip screws in the treatment of femoral neck fractures

OBJECTIVE

To compare the short-term outcomes of the femoral neck system (FNS) with multiple cancellous screws (MCS) and dynamic hip screws (DHS) in the treatment of femoral neck fractures.

METHODS

A retrospective analysis was performed on 157 patients with fresh femoral neck fractures treated with FNS (from September 2019 to October 2020), MCS, and DHS (from January 2018 to October 2020). According to internal fixation methods, all patients were divided into the FNS group (54 cases), MCS group (51 cases), and DHS group (52 cases). Demographic data were also collected, recorded, and compared, including the follow-up time, days of hospitalization, operation time, blood loss, intraoperative fluoroscopy times (IFT), weight-bearing time (WBT), length of femoral neck shortening (LFNS), Harris hip score, and complications (such as internal fixation failure, bone nonunion, and avascular necrosis of the femoral head) between the three groups.

RESULTS

Overall, 157 patients with a mean age of 61.8 (range, 18-89) years were analyzed. In the FNS group, IFT (median 10.5) was significantly lower than that in the MCS group (median 21) and DHS group (median 20.5) (P<0.05), and WBT was significantly earlier than that of the MCS group (P<0.05). In the FNS group, the median hospitalization time, operation time, and blood loss were 2 (2, 4) days, 45 (40-59) min, and 30 (20, 50) ml, respectively. They were all significantly less than 3.5 (3, 6) days, 72 (55-88.75) min, and 50 (30, 50) ml in the DHS group, respectively (P < 0.05). There was no statistical difference in LFNS, quality of reduction, internal fixation failure rate, and Harris hip score at the latest follow-up (P>0.05). No surgical complications such as incision infection, deep infection, pulmonary embolism, or femoral head necrosis were found in any of the three groups.

CONCLUSION

FNS, MCS, and DHS are all effective for femoral neck fractures. However, a lower IFT of FNS shortens the operation time. Compared to MCS, FNS has the advantages of being a simple operation, with early WBT; compared to DHS, a minimally invasive operation is the main advantage of FNS.

Non-sliding Fixation Shows Improved Clinical Outcomes for Displaced Femoral Neck Fractures as Compared to Sliding Fixation

Objective

To compare the clinical outcomes between use of sliding fixation (three cannulated screws, TCS) and non-sliding fixation (four cannulated screws, FCS) in the treatment of femoral neck fractures.

Methods

We retrospectively analyzed 102 patients with fresh femoral neck fractures treated with TCS (60 cases) and FCS (42 cases) between January, 2018 and December, 2019. The demographic data, follow-up time, hospitalization time, operation time, blood loss, length of femoral neck shortening (LFNS), soft tissue irritation of the thigh (STIT), Harris hip score, and complications (such as internal fixation failure, non-union, and avascular necrosis of the femoral head) were also collected, recorded, and compared between the two groups.

Results

A total of 102 patients with an average age of 60.9 (range, 18–86) years were analyzed. The median follow-up time was 25 (22 to 32) months. The LFNS in the FCS group (median 1.2 mm) was significantly lower than that in the TCS group (median 2.8 mm) (P < 0.05). In the Garden classification, the number of displaced fractures in the TCS group was significantly lower than that in the FCS group (P < 0.05). The median hospitalization time, operation time, blood loss, reduction quality, internal fixation failure rate (IFFR), STIT, and Harris hip score were not statistically different between the two groups (P > 0.05). However, in the subgroup analysis of displaced fractures, the LFNS (median 1.2 mm), STIT (2/22, 13.6%), and Harris hip score (median 91.5) of the FCS group at the last follow-up were significantly better than the LFNS (median 5.7 mm), STIT (7/16, 43.8%), and Harris hip score (median 89) of the TCS group (P < 0.05). No complications such as incision infection, deep infection, pulmonary embolism, or femoral head necrosis were found in either group.

Conclusion

TCS and FCS are effective for treating femoral neck fractures. For non-displaced fractures, there was no significant difference in the clinical outcomes between the two groups. However, for displaced fractures, the LFNS of the FCS is significantly lower than that of the TCS, which may reduce the occurrence of STIT and improve the Harris hip score.

Comparison between headless cannulated screws and partially threaded screws in femoral neck fracture treatment: a retrospective cohort study

The choices of the treatments for femoral neck fractures (FNF) remain controversial. The purpose of this study is to evaluate the prognoses of the variable pitch fully threaded headless cannulated screws (HCS) in the fixation of femoral neck fractures and to compare them with those of partially threaded cannulated screws (PCS). Between 1st January 2012 and 31st December 2016, there were 89 patients with the main diagnose of FNF who accepted the treatment of closed reduction cannulated screw fixation in Peking University People’s Hospital. 34 cases of PCS and 23 cases of HCS met the criterion. The characteristics, prognoses and the imaging changes of all cases were described and the differences between the two groups were compared. Statistical analyses were performed using SPSS version 23.0 (SPSS Inc., USA). Mann–Whitney U test, Analysis of Variance and Chi-square test were used. Statistical significance was defined as P value (two sided) less than 0.05. There was no significant difference in the general characteristics, fracture classifications and reduction quality between the two groups. HCS group had a significant lower angle decrease rate (30.4% vs. 58.8%, P = 0.035), femoral neck shortening rate (26.1% vs. 52.9%, P = 0.044) and screw back-sliding rate (21.7% vs. 50.0%, P = 0.032), but a higher screw cut-out rate (21.7% vs. 0.0%, P = 0.008). In non-displacement fracture subgroup, HCS had significant higher Harris Score (92 vs. 90, P = 0.048). Compared with PCS, HCS had a lower screw back-sliding rate, femoral shortening rate, angle decrease rate and similar function score, but would result in more screw cut-outs in displaced FNF. As a conclusion, HCS should not be used in displaced FNF due to its higher screw cut-out rate, and its potential advantage in non-displaced FNF needs to be further proved. Further qualified investigations with a larger scale of patients and longer follow-up are needed in the future.

Breakage of intramedullary femoral nailing or femoral plating: how to prevent implant failure

Introduction

Intramedullary (IM) fixation is the dominant treatment for pertrochanteric and femoral shaft fractures. In comparison to plate osteosynthesis (PO), IM fixation offers greater biomechanical stability and reduced non-union rates. Due to the minimally invasive nature, IM fixations are less prone to approach-associated complications, such as soft-tissue damage, bleeding or postoperative infection, but they are more prone to fat embolism. A rare but serious complication, however, is implant failure. Thus, the aim of this study was to identify possible risk factors for intramedullary fixation (IMF) and plate osteosynthesis (PO) failure.

Materials and methods

We searched our trauma surgery database for implant failure, intramedullary and plate osteosynthesis, after proximal—pertrochanteric, subtrochanteric—or femoral shaft fractures between 2011 and 2019. Implant failures in both the IMF and PO groups were included. Demographic data, fracture type, quality of reduction, duration between initial implantation and nail or plate failure, the use of cerclages, intraoperative microbiological samples, sonication, and, if available, histology were collected.

Results

A total of 24 femoral implant failures were identified: 11 IMFs and 13 POs. The average age of patients in the IM group was 68.2 ± 13.5 years and in the PO group was 65.6 ± 15.0 years, with men being affected in 63.6% and 39.5% of cases, respectively. A proximal femoral nail (PFN) anti-rotation was used in 7 patients, a PFN in one and a gamma nail in two patients. A total of 6 patients required cerclage wires for additional stability. A combined plate and intramedullary fixation was chosen in one patient. Initially, all intramedullary nails were statically locked. Failures were observed 34.1 weeks after the initial surgery on average. Risk factors for implant failure included the application of cerclage wires at the level of the fracture (n = 5, 21%), infection (n = 2, 8%), and the use of an additional sliding screw alongside the femoral neck screw (n = 3, 13%). In all patients, non-union was diagnosed radiographically and clinically after 6 months (n = 24, 100%). In the event of PO failure, the placement of screws within all screw holes, and interprosthetic fixation were recognised as the major causes of failure.

Conclusion

Intramedullary or plate osteosynthesis remain safe and reliable procedures in the treatment of proximal femoral fractures (pertrochanteric, subtrochanteric and femoral shaft fractures). Nevertheless, the surgeon needs to be aware of several implant-related limitations causing implant breakage. These may include the application of tension band wiring which can lead to a too rigid fixation, or placement of cerclage wires at the fracture site.

Smith-Petersen Versus Watson-Jones Approach Does Not Affect Quality of Open Reduction of Femoral Neck Fracture

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.

Changes in radiological parameters during reduction of femoral neck fractures: A radiographic evaluation of cadavers

OBJECTIVE

To investigate changes in the Garden index and other radiological parameters during reduction of femoral neck fractures.

METHODS

Ten healthy, human femoral specimens were obtained. A 2.0 mm diameter Kirschner wire was implanted in the centre of the femoral head. A perpendicular osteotomy was made in the middle of the femoral neck. The distal osteotomy surface was used as the angle of rotation (pronation and supination up to 90° at 10° intervals). Anterior-posterior and lateral view radiographs were taken at different angles. The Garden index and other relevant data were analysed using the picture archiving and communication system. Changes in the area of the femoral head fovea at different rotation angles were measured.

RESULTS

There were no significant differences in the Garden index between 0-30° of pronation and supination (p > .05). For angles of 40-90°, there were statistically significant differences in the Garden index (p < .05). The area of femoral head fovea decreased with increasing pronation angle, and increased with increasing supination angle.

CONCLUSIONS

The Garden index does not change significantly if the angle of fracture rotation is 0-30° (in either pronation or supination) during femoral neck fracture reduction. Therefore, it is impossible to judge the rotation of fracture in this range of angles. The Garden index can detect the rotation of fracture for rotation angles of 40-90° (in either pronation or supination). Changes in the area of the femoral head fovea can help determine the rotation of femoral neck fractures.

LEVEL OF EVIDENCE

Level V.

Analysis on risk factors for neck shortening after internal fixation for Pauwels II femoral neck fracture in young patients

Background

Femoral neck shortening can occur in young patients receiving internal fixation for Pauwels type II femoral neck fracture. The risk factors for neck shortening, which can affect hip function, are not clear. This study aimed to retrospectively identify risk factors for neck shortening after internal fixation with parallel partially threaded cannulated cancellous screws (FPTCS) for Pauwels type II femoral neck fracture in relatively young patients.

Methods

Clinical data from 122 cases with Pauwels type II femoral neck fracture from February 2014 to February 2019 were reviewed and analyzed, and causes of neck shortening were statistically analyzed. And the Chi-squared test or Fisher’s exact test was used to compare indicators. Multivariate analysis was conducted with non-conditional logistic regression analysis.

Results

Statistically significant differences were found in age, sex, BMD, BMI, fracture type, posterior medial cortex comminution, and reduction quality between patients with femoral neck shortening and those without femoral neck shortening. Logistic regression analysis showed that fracture type, posterior medial cortex comminution, and reduction quality were the main risk factors for neck shortening.

Conclusion

Fracture type, posterior medial cortex comminution, and reduction quality can be used as important reference indexes to predict the possibility of neck shortening after internal fixation with FPTCS for Pauwels type II femoral neck fracture in young patients. BMD and BMI may be also risk factors.

Development and validation of a predictive nomogram for postoperative osteonecrosis of the femoral head with cannulated screws fixation

Background

Osteonecrosis of the femoral head (ONFH) remains a major complication of femoral neck fractures. Early interventions require preliminary prediction and detection. In this study, we aimed to evaluate the perioperative variables of postoperative ONFH in femoral neck fracture patients with closed reduction and cannulated screw fixation. We also established and validated an individualized nomogram for the prediction of postoperative ONFH.

Methods

We included 470 patients with ONFH from two hospitals [First Affiliated Hospital of University of Science and Technology of China (n=360) and Southern Branch of the First Affiliated Hospital of the University of Science and Technology of China (n=110)]. We evaluated the prognostic value of multiple perioperative variables using a Cox regression model in the training cohort. We developed a nomogram for the prediction of ONFH using a logistic regression model. We assessed the performance of this nomogram in a validation cohort and evaluated its clinical value.

Results

Of the 470 patients who met the inclusion criteria, 141 (30.0%) developed postoperative ONFH. We found alcohol use [odds ratio (OR), 1.743, 95% confidence interval (CI), 1.042-2.901, P=0.033], cerebrovascular disease (OR, 5.357, 95% CI, 2.318-13.13, P<0.001), interval to surgery (OR, 5.273, 95% CI, 2.724-10.43, P<0.001), Garden classification (OR, 23.17, 95% CI, 6.812-145.3, P<0.001), Garden index (OR, 5.935, 95% CI, 2.670-14.184, P<0.001), interval to partial weight-bearing (OR, 0.053, 95% CI, 0.006-0.296, P=0.002), and six-month Harris hip score (OR, 0.856; 95% CI, 0.792-0.919, P<0.001) were independent predictors of postoperative development of ONFH. Based on these variables, we developed a nomogram that showed good discrimination in both the training [area under the curve (AUC) =0.865] and the validation cohort (AUC =0.877). The favorable performance of this nomogram was also confirmed in the validation cohort.

Conclusions

We developed and validated an easy-to-use nomogram for predicting postoperative ONFH. This nomogram can aid decision-making of intraoperative interventions and postoperative rehabilitation plans for patients, surgeons, and osteo-rehabilitative physicians.

Results of femoral neck screw fixation in 112 under 65-years-old at a minimum 2 years' follow-up

INTRODUCTION

Failure rates for screw fixation in femoral neck fracture in young patients are often high, with risk of aseptic femoral head osteonecrosis and non-consolidation. The present study sought to identify factors for success or failure of internal fixation according to: 1) initial treatment; 2) initial reduction quality; and 3) population characteristics.

HYPOTHESIS

The study hypothesis was that population, fracture type, initial treatment and reduction quality can predict survival.

MATERIAL AND METHODS

A retrospective study included all cases of femoral neck fracture in under 65-years-old treated by screwing in our center: i.e., 112 patients. Patient characteristics, time to surgery were collated; surviving patients were followed up at a minimum 24 months. Reduction quality was assessed on X-rays in 3 dimensions and cervico-diaphyseal angle.

RESULTS

Mean follow-up was 5.3±3.0 years [range, 2.0-13.6 years]. At 2 years, 23 of the 112 patients (20.5%) had developed complications: 10 osteonecroses (8.9%) and 13 non-unions (11.6%). Known hip osteonecrosis risk factors showed no significant association with survival. Failure rates were significantly higher in unstable (Garden≥3) than stable (Garden≤2) fracture: HR=2.77 [95%CI: 1.09-7.02]; p=0.025. There was no significant association with time to treatment (≤6 hours): HR=1.08 [95%CI: 0.46-2.54]; p=0.86. On 2-year radiographs, mean shortening on the z-axis was 12.3±4.8mm [-0.7 to 26.2], 8.5±5.0mm [-6.8 to 23.9] on the x-axis, and 6.4±6.1mm [-6.3 to 25.3] on the y-axis. There was a significant negative correlation between z shortening and HOOS pain component (r=-0.38; p=0.005), a non-significant negative correlation with quality of life (r=-0.20; p=0.16), and a significant negative correlation with sports activity (r=-0.28; p=0.039).

CONCLUSION

The present series showed lower rates of complications and of arthroplasty than in the literature. Internal fixation seemed to be indicated even at an interval of 6 hours or more.

LEVEL OF EVIDENCE

IV, retrospective study.

Open Reduction Is Associated With Greater Hazard of Early Reoperation After Internal Fixation of Displaced Femoral Neck Fractures in Adults 18-65 Years

OBJECTIVES

To determine (1) which factors are associated with the choice to perform an open reduction and (2) by adjusting for these factors, if the choice of reduction method is associated with reoperation.

DESIGN

Retrospective cohort study with radiograph and chart review.

SETTING

Twelve Level 1 North American trauma centers.

PATIENTS

Two hundred thirty-four adults 18-65 years of age with an isolated, displaced, OTA/AO type 31-B2 or type 31-B3 femoral neck fracture treated with internal fixation with minimum of 6-month follow-up or reoperation. Exclusion criteria were pathologic fractures, associated femoral head or shaft fractures, and primary arthroplasty.

INTERVENTION

Open or closed reduction technique during internal fixation.

MAIN OUTCOME

Cox proportional hazard of reoperation adjusting for propensity score for open reduction based on injury, demographic, and medical factors. Reduction quality was assessed by 3 senior orthopaedic traumatologists as "acceptable" or "unacceptable" on AP and lateral postoperative radiographs.

RESULTS

Median follow-up was 1.5 years. One hundred six (45%) patients underwent open reduction. Reduction quality was not significantly affected by open versus closed approach (71% vs. 69% acceptable, P = 0.378). The propensity to receive an open reduction was associated with study center; younger age; male sex; no history of injection drug use, osteoporosis, or cerebrovascular disease; transcervical fracture location; posterior fracture comminution; and surgery within 12 hours. A total of 35 (33%) versus 28 (22%) reoperations occurred after open versus closed reduction (P = 0.056). Open reduction was associated with a 2.4-fold greater propensity-adjusted hazard of reoperation (95% confidence interval 1.3-4.4, P = 0.004). A total of 35 (15%) patients underwent subsequent total hip arthroplasty or hemiarthroplasty.

CONCLUSIONS

Open reduction of displaced femoral neck fractures in nonelderly adults is associated with a greater hazard of reoperation without significantly improving reduction. Prospective randomized trials are indicated to confirm a causative effect of open versus closed reduction on outcomes after femoral neck fracture.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Use of fully threaded cannulated screws decreases femoral neck shortening after fixation of femoral neck fractures

BACKGROUND

Femoral neck fractures (FNF) are becoming increasingly common as population ages. Nondisplaced fractures are commonly treated by cancellous, parallel placed, partially threaded cannulated screws (PTS). This allows controlled fracture impaction. However, sliding implants can lead to femoral neck shortening (FNS) that has been shown to be correlated with reduced quality of life and impaired gait pattern. Recently, in our institution we have changed the fixation of FNF to fully threaded screws (FTS) with or without an additional partially threaded screw in order to minimize this phenomenon. The aim of this study was to compare the FNS in patients treated with FTS as compared with our historical controls treated with PTS.

PATIENTS AND METHODS

Between 2014 and 2016, 38 patients with FNF were treated with FTS. Out of the 38, 24 were available for radiographic follow-up. 41 patients treated previously with PTS were available as a control group. Radiographic analysis was performed to assess the FNF in three vectors: Horizontal (X), Vertical (Y) and overall (Z) according to the neck-shaft angle.

RESULTS

Time for admission to surgery was longer in the PTS group (p = 0.04). Patient demographics and major complication rates were similar in the two patient groups. Average FNS in the X axis was significantly smaller in the FTS group than in the PTS group (2.8 ± 3.6 vs 7.6 ± 4.2 mm, p < 0.01) as well as the Y axis (1.2 ± 2.6 vs 4.9 ± 4.2 mm, p < 0.01) and thus also decreased overall Z shortening (2.3 ± 3.5 vs 6.23 ± 4.5 mm, p < 0.01). There was a tendency towards a more valgus reduction in the PTS (137° vs 134°, p = 0.08). There was a significantly smaller number of FTS patients with moderate (5-10 mm) or severe (> 10 mm) FNS. Screw pull-out > 5 mm occurred in 17/41 patients in the PTS but none in the FTS group (p < 0.01).

CONCLUSION

This study proves that use of FTS improves the radiographic results following FNF fixation using cannulated screws.

Digital blinding of radiographs to mask allocation in a randomized control trial

AIM

To demonstrate the effectiveness of a digital radiographic altering technique in concealing treatment allocation to blind outcome assessment of distal femur fracture fixation.

METHODS

Digital postoperative anteroposterior and lateral radiographs from a sample of 33 randomly-selected patients with extra-articular distal femur fractures treated by surgical fixation at a Level 1 trauma center were included. Using commercially available digital altering software, we devised a technique to blind the radiographs by overlaying black boxes over the implant hardware while preserving an exposed fracture site for assessment of fracture healing. Three fellowship-trained surgeons evaluated a set of blinded radiographs twice and a control set of unblinded radiographs once. Each set of radiographs were reviewed independently and in a randomly-assigned order. The degrees of agreement and disagreement among evaluators in identifying implant type while reviewing both blinded and unblinded radiographs were assessed using the Bang Blinding Index and James Blinding Index. The degree of agreement in fracture union was assessed using kappa statistics.

RESULTS

The assessment of blinded radiographs with both the Bang Blinding Index (BBI) and James Blinding Index (JBI) demonstrated a low degree of evaluator success at identifying implant type (Mean BBI, far cortical locking: -0.03, SD: 0.04; Mean BBI, standard screw: 0, SD: 0; JBI: 0.98, SD: 0), suggesting near perfect blinding. The assessment of unblinded radiographs with both blinding indices demonstrated a high degree of evaluator success at identifying implant type (Mean BBI, far cortical locking: 0.89, SD: 0.19; Mean BBI, standard screw: 0.87, SD: 0.04; JBI: 0.26, SD: 0.12), as expected. There was moderate agreement with regard to assessment of fracture union among the evaluators in both the blinded (Kappa: 0.38, 95%CI: 0.25-0.52) and unblinded (Kappa: 0.35, 95%CI: 0.25-0.45) arms of the study. There was no statistically significant difference in fracture union agreement between the blinded and unblinded groups.

CONCLUSION

The digital blinding technique successfully masked the surgeons to the type of implant used for surgical treatment of distal femur fractures but did not interfere with the surgeons’ ability to reliably evaluate radiographic healing at the fracture site.

Treatment of femoral neck fracture with percutaneous compression plate: preliminary results in 74 patients

OBJECTIVE

The purpose of this study was to present the surgical technique and clinical results of percutaneous compression plate (PCCP) for the treatment of femoral neck fractures.

METHODS

Between December 2010 and April 2013, 74 consecutive patients with 74 femoral neck fractures were treated by closed reduction and PCCP implants in our university hospital. Their mean age was 51.3 years (range, 15-83 years); 38 (51.4%) were male and 46 (62.2%) of the fractures were on the left. The patients' clinical and radiographic data were analyzed retrospectively.

RESULTS

There were 45 undisplaced (60.8%) and 29 displaced fractures (39.2%). Eight patients (10.8%) were lost to follow-up. The mean duration of follow-up was 18.8 months for the remaining 66 patients. At the last follow-up, mean Harris hip score was 92.9 (range, 75-100), and 65 patients (98.5%) had excellent and good outcomes. Sixty-five patients (98.5%) were able to walk independently and one (1.5%) with walking-sticks. The mean time to clinical fracture healing was 3.9 months. There were no cases of nonunion. Two patients (3.0%) had delayed union and two (3.0%) developed avascular necrosis, one of 29 (3.7%) with a displaced fracture and one of 45 (2.6%) with an undisplaced fracture. There were no other complications or prosthetic replacement.

CONCLUSIONS

PCCP is a stable internal fixation device that resists axial and rotational stresses. Our PCCP procedure has a low incidence of nonunion and avascular necrosis.

Outcome of proximal femoral fractures caused by cycling in the young and mid-aged

BACKGROUND

Cycling is gaining more popularity both as a sport, on and off-road and also as a means of commute. Cycling accidents harbour significant injury risks including fractures. Proximal femoral fractures are uncommonly associated with cycling in the young adult population. The purpose of this study is to describe this unique pattern of injury as well as the outcome of proximal femoral fractures caused by cycling in the young to mid age population.

STUDY DESIGN

retrospective cohort study. 23 fractures in 22 patients were available for analysis. 11 were femoral neck fractures, with six displaced ones, and the rest trochanteric fractures. 21 patients were male patients, and the average age was 42 (range 27-60). All patients but two were operated within 24 h from admission. Radiographic analysis included reduction quality, fracture classification and arthritic changes. Clinical outcome was measured using SF-12 and Oxford hip scores.

RESULTS

All fractures healed. Two patients with displaced femoral neck fractures developed avascular necrosis requiring arthroplasty. One patient developed an AVN 2 years after a stable trochanteric fracture but did not require an arthroplasty as of yet. Eight patients required hardware removal due to symptoms. 77% of patients had resumed cycling at the pre-injury level. Mean SF-12 score was 47.1 ± 11.7 for the physical component and 53.7 ± 6.3 for the mental component. Mean oxford hip score as was 40.1 ± 12.2. Radiographic analysis revealed good to acceptable reduction quality. Fracture type, age, cycling type and reduction were not significantly associated with outcome.

CONCLUSION

Proximal femoral fractures caused by cycling in young to mid-aged adults are an emerging pattern of injury. Overall favourable result can be expected in the majority of cases, with displaced femoral neck fractures having a risk for AVN. Further delineation of the exact cause for this phenomenon is required with possible intervention for injury prevention.

Radiographic displacement in pelvic ring disruption: reliability of 3 previously described measurement techniques

BACKGROUND

The literature on pelvic ring disruptions is based largely on nonstandardized and nonvalidated radiographic outcomes. A thorough review of the literature revealed only 3 described methods for measuring radiographic displacement and 1 frequently used grading system for displacement. We aimed to test the reliability of these previously published radiographic measurement methods and grading system.

METHODS

Five separate observers measured radiographic displacement on the standardized pre- and postoperative anteroposterior, inlet, and outlet views of 25 patients with surgically treated Tile B and C pelvic fractures. The readers measured their initial impression based on the Tornetta and Matta grading system (excellent, good, fair, and poor). Next, they measured displacement using the inlet and outlet ratio as described by Sagi, the cross measurement technique as described by Keshishyan, and the absolute displacement method (ADM) as described by Lefaivre. The millimeter measurement obtained by the ADM was converted using the Tornetta and Matta grading system. Each continuous measure was compared for interobserver reliability using intraclass correlations (ICCs), and the categorical outcomes were compared using a kappa statistic. Finally, the relationship of the initial impression to the grade as determined by the ADM was compared using kappa agreement.

RESULTS

The agreement among observers based on initial impression was poor (kappa statistic, 0.306) but was fair among those reductions that were excellent (κ = 0.495). Using the Sagi method, the reliability ICC was moderate for the postoperative inlet [0.515, 95% confidence interval (CI), 0.338-0.702] and outlet ratio (0.594, 95% CI, 0.423-0.760) but almost perfect in preoperative radiographs (inlet: 0.814, 95% CI, 0.703-0.901; outlet: 0.863, 95% CI, 0.775-0.929). The ICCs for all interpretations of the Keshishyan technique were excellent but were highest when considered as a ratio (preoperative: 0.938, 95% CI, 0.894-0.969; postoperative: 0.912, 95% CI, 0.850-0.955). Using the ADM, the location and film used for measurement had poor agreement, and the ICC for the measurement in millimeters was moderate (preoperative: 0.522, 95% CI, 0.342-0.708; postoperative: 0.432, 95% CI, 0.255-0.634) and the kappa agreement poor when converted using the Tornetta and Matta scale (κ = 0.2190). The agreement between the impression and the converted grade from the ADM was poor (κ = 0.2520).

CONCLUSIONS

Radiographic measurement in pelvic x-rays to date has been nonvalidated, and we found the interobserver reliability on common methods, including overall impression and absolute displacement in millimeters, to be poor. The inlet/outlet ratio as described by Sagi was reliable only with wide displacement. The cross measurement technique allows least observer choice and had excellent reliability but does not give a measurement that we can easily interpret based on convention in pelvic fracture description.

Assessment of radiographic fracture healing in patients with operatively treated femoral neck fractures

OBJECTIVES

This study was conducted to determine interrater and intrarater reliabilities on the healing assessment of femoral neck fractures between orthopedic surgeons and radiologists and to test the performance of a checklist system for hip fracture healing.

METHODS

We developed and used a scoring system [radiographic union score in hip fracture (RUSH) score] to determine the validity of quantifying fracture healing. A panel of 6 reviewers (3 orthopedic surgeons and 3 radiologists) independently assessed fracture healing with the RUSH system using radiographs of 150 femoral neck fractures at various stages in healing on 2 occasions 4 weeks apart.

RESULTS

Using subjective assessment, the interrater agreement between reviewer groups for fracture healing was fair [intraclass coefficient = 0.22, 95% confidence interval (CI): 0.01-0.41] with no significant difference in agreement within the orthopedic surgeon and radiologist groups (0.17 vs. 0.21). There was higher agreement for fracture healing using the RUSH score (intraclass coefficient = 0.53, 95%CI: 0.30-0.69) compared with physician impression of healing, highlighting the difficulties with plain radiographic assessments of healing. Intrarater agreement was consistently high across all measures for both surgeons and radiologists. The RUSH score and medial cortex bridging correlated well with overall assessment of healing (r = 0.868 and 0.643, respectively).

CONCLUSIONS

The level of agreement between and within orthopedic surgeon and radiologist reviewers in the assessment of fracture healing is low, though intrarater agreement is high. The RUSH score shows promise as a tool to improve agreement on fracture healing. Studies evaluating reliability and accuracy of healing with clinical information and temporal evaluation are needed and may further improve agreement.

The definition of polytrauma: variable interrater versus intrarater agreement--a prospective international study among trauma surgeons

BACKGROUND

The international trauma community has recognized the lack of a validated consensus definition of "polytrauma." We hypothesized that using a subjective definition, trauma surgeons will not have substantial agreement; thus, an objective definition is needed.

METHODS

A prospective observational study was conducted between December 2010 and June 2011 (John Hunter Hospital, Level I trauma center). Inclusion criteria were all trauma call patients with subsequent intensive care unit admission. The study was composed of four stages as follows: (1) four trauma surgeons assessed patients until 24 hours, then coded as either "yes" or "no" for polytrauma, and results compared for agreement; (2) eight trauma surgeons representing the United States, Germany, and the Netherlands graded the same prospectively assessed patients and coded as either "yes" or "no" for polytrauma; (3) 12 months later, the original four trauma surgeons repeated assessment via data sheets to test intrarater variability; and (4) individual subjective definitions were compared with three anatomic scores, namely, (a) Injury Severity Score (ISS) of greater than 15, (b) ISS of greater 17, and (c) Abbreviated Injury Scale (AIS) score of greater than 2 in at least two ISS body regions.

RESULTS

A total of 52 trauma patients were included. Results for each stage were as follows: (1) κ score of 0.50, moderate agreement; (2) κ score of 0.41, moderate agreement; (3) Rater 1 had moderate intrarater agreement (κ score, 0.59), while Raters 2, 3, 4 had substantial intrarater agreement (κ scores, 0.75, 0.66, and 0.71, respectively); and (4) none had most agreement with ISS of greater than 15 (κ score, 0.16), while both definitions ISS greater than 17 and Abbreviated Injury Scale (AIS) score of greater than 2 in at least two ISS body regions had on average fair agreement (κ scores, 0.27 and 0.39, respectively).

CONCLUSION

Based on subjective assessments, trauma surgeons do not agree on the definition of polytrauma, with the subjective definition differing both within and across institutions.

Interrater reliability of chinese medicine diagnosis in people with prediabetes

Background. Achieving reproducibility in research design is challenging when patient cohorts under study are inconsistently defined. Traditional Chinese medicine (TCM) diagnosis is one example where inconsistency between practitioners has been found. We hypothesise that the use of a validated instrument may improve consistency. Biochemical biomarkers may also be used enhance reliability. Methods. Twenty-seven participants with prediabetes were assessed by two TCM practitioners using a validated instrument (TEAMSI-TCM). Inter-rater reliability was summarised using percentage agreement and the kappa coefficient. One-way ANOVA and Tukey's post hoc test were used to test links between TCM diagnosis and biomarkers. Results. The two practitioners agreed on primary diagnosis of 70% of participants. kappa = 0.56 (P < 0.001). The three predominant TCM diagnostic patterns for people with prediabetes were Yin deficiency, Qi and Yin deficiency and Spleen qi deficiency. The Spleen Qi deficiency with Damp cohort had statistically significant higher fasting glucose, higher insulin, higher insulin resistance, higher HbA1c and lower HDL than those with Qi and Yin deficiency. Conclusions. Using the TEAMSI-TCM resulted in moderate interrater reliability between TCM practitioners. This study provides initial evidence of variation in the biomarkers of people with prediabetes according to the different TCM patterns which may suggest a route to further improving interrater reliability.

Radiographic union score for hip substantially improves agreement between surgeons and radiologists

Background

Despite the prominence of hip fractures in orthopedic trauma, the assessment of fracture healing using radiographs remains subjective. The variability in the assessment of fracture healing has important implications for both clinical research and patient care. With little existing literature regarding reliable consensus on hip fracture healing, this study was conducted to determine inter-rater reliability between orthopedic surgeons and radiologists on healing assessments using sequential radiographs in patients with hip fractures. Secondary objectives included evaluating a checklist designed to assess hip fracture healing and determining whether agreement improved when reviewers were aware of the timing of the x-rays in relation to the patients’ surgery.

Methods

A panel of six reviewers (three orthopedic surgeons and three radiologists) independently assessed fracture healing using sequential radiographs from 100 patients with femoral neck fractures and 100 patients with intertrochanteric fractures. During their independent review they also completed a previously developed radiographic checklist (Radiographic Union Score for Hip (RUSH)). Inter and intra-rater reliability scores were calculated. Data from the current study was compared to the findings from a previously conducted study where the same reviewers, unaware of the timing of the x-rays, completed the RUSH score.

Results

The agreement between surgeons and radiologists for fracture healing was moderate for “general impression of fracture healing” in both femoral neck (ICC = 0.60, 95% CI: 0.42-0.71) and intertrochanteric fractures (0.50, 95% CI: 0.33-0.62). Using a standardized checklist (RUSH), agreement was almost perfect in both femoral neck (ICC = 0.85, 95% CI: 0.82-0.87) and intertrochanteric fractures (0.88, 95% CI: 0.86-0.90). We also found a high degree of correlation between healing and the total RUSH score using a Receiver Operating Characteristic (ROC) analysis, there was an area under the curve of 0.993 for femoral neck cases and 0.989 for intertrochanteric cases. Agreement within the radiologist group and within the surgeon group did not significantly differ in our analyses. In all cases, radiographs in which the time from surgery was known resulted in higher agreement scores compared to those from the previous study in which reviewers were unaware of the time the radiograph was obtained.

Conclusions

Agreement in hip fracture radiographic healing may be improved with the use of a standardized checklist and appears highly influenced by the timing of the radiograph. These findings should be considered when evaluating patient outcomes and in clinical studies involving patients with hip fractures. Future research initiatives are required to further evaluate the RUSH checklist.

The need to standardize functional outcome in randomized trials of hip fracture: a review using the ICF framework

OBJECTIVES

The choice of ideal outcome assessment is complex with the ever-growing number of possible instruments found in the orthopaedic literature. It is critical to reach a worldwide consensus approach in identifying the specific measures to be used in study designs for evaluating treatment of patients with hip fracture. In this article, we present results from a systematic review of the measures being used currently to assess functional outcome in randomized trials. We used the International Classification of Functioning Disability and Health (ICF) framework for conceptualizing outcome after hip fracture trauma from a body, individual, and societal perspective.

DATA SOURCES

Relevant articles from 1980 to 2008 (week 52) were found using PubMed, Ovid MEDLINE, Cochrane, Ovid Healthstar, EMBASE, and CINAHL.

STUDY SELECTION

Studies were included if (1) patients were older than 65 years and managed postoperatively after a hip fracture and (2) the studies were randomized and in the English language.

DATA EXTRACTION

The intervention, sample size, follow-up, intention-to-treat analysis, mode of administration, and functional outcome domains and concepts using the ICF were recorded for each study.

DATA SYNTHESIS

Ninety-seven studies containing 82 different instruments for assessing functional outcome were included. Those trials with a low risk of bias relied upon standardized patient-reported outcomes when compared with those trials with a high risk of bias that adopted more investigator-developed instruments. Nineteen percent of the trials used the Harris hip score, 14% used the Katz activities of daily living index, and 10% used the new mobility score.

CONCLUSIONS

We believe that standardized patient-reported outcomes should be used to assess functional outcome after hip fracture and more rigor is needed when conducting surgical trials in this area. Variation in outcome measures across trials leads to several problems. Clinicians may not be able to interpret their findings when different measures are used. Researchers will not be able to calculate summary treatment effects. Our findings are based on a process for delineating the categories from within the ICF framework that may serve, in the future, as a comprehensive foundation of content for outcomes in the area of hip fractures.

Failed internal fixation of femoral neck fractures

BACKGROUND

There are two types of surgical treatment for fractures of the femoral neck; internal fixation and arthroplasty. Internal fixation is associated with a higher risk of complications such as secondary displacement, non-union and avascular necrosis. To improve treatment results of internal fixation, we have tried to identify procedure related risk-factors associated with fixation failure.

MATERIAL AND METHOD

A retrospective study was conducted based on the medical records and X-ray images of 337 patients sustaining intracapsular fractures of the hip during the period 1999-2000. The patients were treated with closed reduction and internal fixation at Oslo University Hospital, Aker. The reduction of the fracture and the placement of the fixation implants were evaluated and scored (six points representing best achievable result).

RESULTS

Fixation failed in 23 (18,3 %) out of 126 patients with displaced fractures awarded six points for the reduction. In contrast, fixation failed in five (50 %) out of ten patients given a score of three points or less (p &equals; 0.017). The risk of non-union increased when patients were treated more than 48 hours after the initial injury. In this group, 5 (25 %) out of 20 patients developed non-union compared to 16 (8 %) out of 200 patients treated within 48 hours (p &equals; 0.014).

INTERPRETATION

Our findings emphasize the importance of achieving anatomical reduction of displaced femoral neck fractures, and to perform surgery within 48 hours unless an acute medical condition needs to be stabilized.

Methodology and interpretation of radiographic outcomes in surgically treated pelvic fractures: a systematic review

OBJECTIVE

To identify and evaluate previously described methods for the measurement, and interpretation, of radiographic outcomes of operatively treated pelvic fractures.

DATA SOURCES

A systematic review of the available literature was performed using all major databases (MEDLINE, EMBASE, MEDLINE IN-PROGRESS, and Cochrane Central) in August 2009.

STUDY SELECTION

Inclusion criteria were case series, cohort studies, or clinical trials regarding orthopaedic treatment of acute traumatic pelvic ring fractures treated surgically in adults, with at least 12 weeks of radiographic follow-up. Exclusion criteria were case reports or case series of <10 patients, review articles, foreign language articles, and series where time frame of outcome measurement was not stated were excluded.

DATA EXTRACTION

Modality, and timeline, of the radiographic assessment was recorded. Next, the description of the method of radiographic measurement technique used was scrutinized for standardization. The interpretation of the radiographic measurement was evaluated, and any grading scale used was recorded. The interpretation of the quality of the radiographic result as described by each author was recorded. Finally, a qualitative methodological analysis was performed.

DATA SYNTHESIS

Number of standardized radiographic assessment techniques used (3 of 31) and interpretation scales used (13 of 31) were calculated. Nonweighted mean follow-up time (30.6 months) and overall positive radiographic outcomes were calculated (78.6% good or excellent).

CONCLUSIONS

Reporting of radiographic outcomes in pelvic fractures has been done using largely unstandardized and universally untested measurement techniques. The interpretations of these measurements are also inconsistent and untested. Substantive future research is needed in this area.

Femoral neck shortening and varus collapse after navigated fixation of intracapsular femoral neck fractures

OBJECTIVE

Assessing femoral neck shortening (FNS) and varus collapse after internal fixation of femoral neck fractures using computerized navigation (CN).

DESIGN

Retrospective cohort study.

SETTINGS

Academic Level I trauma center.

PATIENTS AND METHODS

Forty-one patients who had healed femoral neck fractures treated with CN between the years 2003 and 2008. Average age was 65 years (range, 14-91 years). Thirty-six patients had nondisplaced fractures and five had displaced fractures.

INTERVENTION

Screws were placed using CN in an inverted triangle formation Follow-up films were digitized into a PACS system, calibrated, and analyzed using CAD software.

OUTCOME MEASURES

The following parameters were recorded: abductor lever arm shortening (termed x), corresponding vertical femur shortening (termed y), and the resultant femoral neck shortening vector (z). Fifteen patients were available for clinical outcome measures by the means of SF-12 survey

RESULTS

Significant FNS of the x component (greater than 5 mm) occurred in 30 of 42 (71%) patients with severe shortening (greater than 10 mm) in 25% of the patients. Significant y shortening occurred in 43% of the patients and severe shortening in 17%. Overall (z) femoral neck shortening occurred in 56% of the patients with severe shortening in 22% of patients. Varus collapse (greater than 5°) did not occur in any patient. Screw pullout (greater than 5 mm) occurred in 17 (41%) patients. Seven patients required late (greater than 6 months) arthroplasty postoperatively. FNS did not significantly correlate with fracture type, quality of reduction, age, or neck shaft angle. SF-12 results were negatively correlated with overall FNS.

CONCLUSIONS

Our results show a high degree of FNS associated with the use of CN for fixation of femoral neck fractures, similar to recently published series using nonnavigated implants. However, no varus collapse occurred in our series. Our preliminary clinical data show a trend toward an adverse effect of FNS on quality-of-life measures.

Provider factors associated with intramedullary nail use for intertrochanteric hip fractures

BACKGROUND

Intramedullary nails provide no clear outcomes benefit in the majority of patients with intertrochanteric hip fracture, yet their use in the United States continues to increase. Non-patient factors that are associated with intramedullary nail use among Medicare patients have not been examined. The goal of this study was to identify the surgeon and hospital characteristics that were associated with the use of intramedullary nails compared with plate-and-screw devices among elderly Medicare patients with intertrochanteric hip fractures.

METHODS

Medicare beneficiaries who were sixty-five years of age or older and underwent inpatient surgery to treat an intertrochanteric femoral fracture with use of an intramedullary nail or a plate-and-screw device were identified from the United States Medicare files for 2000 to 2002. Surgeon and hospital characteristics from the Medicare provider enrollment files were merged with the claims. Generalized linear mixed models with fixed and random effects modeled the association between surgeon and hospital factors and intramedullary nail use (compared with plate and screws), controlling for patient age, sex, and race; subtrochanteric fracture; Charlson comorbidity score; nursing home residence; and Medicaid-administered assistance. The adjusted odds ratios of receiving an intramedullary nail by year, surgeon, and hospital factors are reported.

RESULTS

There were 192,365 claims for surgery to treat an intertrochanteric hip fracture that met the inclusion criteria and matched with surgeon and hospital information. There were 15,091 surgeons who performed intertrochanteric hip fracture surgeries in Medicare patients in 3480 hospitals between March 1, 2000, and December 31, 2002. The surgeon factors associated with intramedullary nail use include younger surgeon age (less than forty-five years old), an osteopathy degree, and operating at more than one hospital. The hospital factors associated with intramedullary nail use include a higher volume of intertrochanteric hip fracture surgeries, teaching hospital status, and having resident assistance during surgery. Surgeon factors improved the model fit more than hospital factors.

CONCLUSIONS

The use of intramedullary nails was strongly associated with early-career surgeons and surgeon training programs. Our findings suggest that orthopaedic faculty at teaching hospitals and younger surgeons may be selecting orthopaedic implants on the basis of factors other than clinical outcomes evidence. We expect that intramedullary nail use will continue to increase as long as new surgeons are preferentially trained in intramedullary nailing procedures and surgeon reimbursement remains insulated from the treating hospital's burden of their choices for higher cost devices under the Medicare payment system.