Early Results in Non-Displaced Femoral Neck Fractures Using the Femoral Neck System

Outcomes of internal fixation with Femoral Neck System (FNS) for intracapsular femoral neck fractures

Background

Internal fixation of hip fractures is associated with high reoperation rates. This study investigated the reoperation rates after internal fixation with the femoral neck system (FNS).

Materials and Methods

A single-institution cohort study was conducted on patients aged 18 years or older who sustained intracapsular femoral neck fractures and underwent internal fixation with a fixed-angle implant. Surgeons, patients, and investigators were not blinded. The primary outcome was any hip reoperation at the final follow-up. Secondary outcomes were to characterize a cohort of patients regarding demographics, fracture classification, intraoperative findings, postoperative fracture complications and union rates, and postoperative pain.

Results

This study found that internal fixation with FNS for intracapsular femoral neck fractures was associated with a 23% rate of revision surgery. Of the initial 94 patients who received FNS internal fixation, 44 patients were included for analysis; of those, 10 patients underwent revision surgery. Patients had a 22% rate of in-hospital medical adverse events with a 30-day readmission rate of 9%. Increasing body mass index was associated with increased revision rates (P = 0.037). Patients who sustained displaced femoral neck fractures had a significant decrease in SF-12 Mental Health Composite, SF-12 Physical Health Composite, and quality-of-life subscale scores.

Conclusions

The FNS is a viable alternative for internal fixation of intracapsular femoral neck fractures. The observed rate of revision after internal fixation was comparable with previously published outcomes following fixation with cannulated screws and sliding hip screws.

Level of Evidence

Level IV, Therapeutic Study.

Comparison of young femoral neck fractures treated by femoral neck system, multiple cancellous screws and dynamic hip screws: a retrospectively comparison study

BACKGROUND

Implant choice for the fixation of femoral neck fracture is one of the most important management controversies. This study aims to evaluate and compare the short-term outcomes associated with the use of the Femoral Neck System (FNS), Multiple Cancellous Screws (MCS), and Dynamic Hip Screws (DHS) in treating femoral neck fractures in a young patient population.

METHODS

From June 2018 to June 2021, a total of 120 surgeries for a primary femoral neck fracture were retrospectively analyzed. This review encompassed demographic details of the patients and the mechanisms behind the injuries. Key surgical parameters such as operation duration, intraoperative blood loss, fluoroscopy duration, and hospital stay were meticulously documented. The employed surgical technique was described. All patients were followed up at 6 weeks, 3 months, 6 months, and 12 months postoperatively. Avascular necrosis of the femoral head (AVN), nonunion, malreduction, implant failure or other complications were noted. The functional status at the last follow-up was assessed using the Harris functional scoring criteria.

RESULTS

There were 90 males and 30 females, with a mean age of 40.4 years. As to patient characteristics, there were no significant differences between the three groups. DHS group showed longer operation time(52.15 ± 4.80 min), more blood loss(59.05 ± 5.87 ml) and longer time of hospitalization(7.6 ± 0.90 d) than FNS group (39.65 ± 2.84 min, 45.33 ± 9.63 ml and 4.87 ± 0.48 d) and MCS group (39.45 ± 3.10 min, 48.15 ± 7.88 ml and 5.04 ± 0.49 d) (p < 0.05). In addition, the time of fluoroscopy in FNS group (15.45 ± 3.67) was less than that in MCS group (26.3 ± 4.76) and DHS group (27.1 ± 5.67) (p < 0.05). The cost of FNS group(44.51 ± 2.99 thousand RMB) was significantly higher than the MCS and DHS groups. The FNS, MCS and DHS groups showed a similar mean length of femoral neck shortening (LFNS) and Harris score. The FNS, MCS and DHS groups showed a similar mean rate of AVN and internal fixation failure.

CONCLUSIONS

Following successful fracture reduction, FNS, MCS, and DHS are effective for in the young femoral neck fractures. No difference was found in complications between the three groups. However, the reduced fluoroscopy time associated with FNS contributes to shorter operation durations. The adoption of minimally invasive techniques correlates with decreased blood loss and shorter hospital stays. Nevertheless, these advantages may be offset by the potential economic burden they impose.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Femoral neck system vs. cannulated screws on treating femoral neck fracture: a meta-analysis and system review

Objective

This meta-analysis aimed to compare the relative safety and efficacy of cannulated compression screw (CCS) and femoral neck system (FNS) in treating patients with femoral neck fractures and to provide evidence-based medical evidence for FNS in treating femoral neck fractures.

Methods

PubMed, Embase, Cochrane, and China National Knowledge Infrastructure databases were searched to collect outcomes related to femoral neck fractures treated with FNS and CCS, including time to fracture healing, incidence of non-union, incidence of osteonecrosis of the femoral head, incidence of failure of internal fixation, rate of femoral neck shortening, Harris hip score, Barthel index, operative time, intraoperative blood loss, fluoroscopy frequency, and complications. A meta-analysis was performed using RevManv5.4 (The Cochrane Collaboration) and Stata v14.0 software.

Results

This analysis included 21 studies involving 1,347 patients. The results showed that FNS was superior to CCS in terms of fracture healing time [mean difference (MD) = -0.75, 95% CI = (-1.04, -0.46), P < 0.05], incidence of bone non-union [odds ratio (OR) = 0.53, 95% CI = (0.29, 0.98), P = 0.04], incidence of osteonecrosis of the femoral head [OR = 0.49, 95% CI = (0.28, 0.86), P = 0.01], incidence of internal fixation failure [OR = 0.30, 95% CI = (0.18, 0.52), P < 0.05], rate of femoral neck shortening [OR = 0.38, 95% CI = (0.27, 0.54), P > 0.05], Harris hip score [MD = 3.31, 95% CI = (1.99, 4.63), P < 0.001], Barthel index [MD =  4.31, 95% CI = (3.02, 5.61), P < 0.05], intraoperative bleeding [MD = 14.72, 95% CI = (8.52, 20.92), P < 0.05], fluoroscopy frequency [OR = 0.53, 95% CI = (0.29, 0.98), P = 0.04], and complications [OR = 0.31, 95% CI = (0.22, 0.45), P < 0.05]. The difference between FNS and CCS in operative time was not statistically significant [MD = -2.41, 95% CI = (-6.88, 2.05), P = 0.29].

Conclusion

FNS treatment of femoral neck fracture can shorten the fracture healing time; reduce the incidence and translucent rate of bone non-union, osteonecrosis of the femoral head, and internal fixation failure; reduce intraoperative blood loss and postoperative complications; and improve hip joint function and activity. We are confident in the findings that FNS, an effective and safe procedure for internal fixation of femoral neck fractures, is superior to CCS.

Is new always better: comparison of the femoral neck system and the dynamic hip screw in the treatment of femoral neck fractures

BACKGROUND

Hip fractures in the elderly population are common and the number of patients is rising. For young and geriatric patients with undisplaced fractures osteosynthesis is the primary type of treatment. The dynamic hip screw (DHS) is around for many years and proved its value especially in displaced fractures. Since 2018 the femoral neck system (FNS) is available as an alternative showing promising biomechanical results. The aim of this study is to evaluate clinical results of the FNS and compare it to the DHS.

MATERIALS AND METHODS

Patients older than 18 years with Garden I-IV fractures that were treated with osteosynthesis in a level 1 trauma center were included in the study. Between January 2015 and March 2021, all patients treated with FNS (1-hole plate, DePuy-Synthes, Zuchwil, Switzerland) or DHS (2-hole plate, DePuy-Synthes, Zuchwil, Switzerland) for proximal femur fractures were included in the study. Closed reduction was achieved using a traction table. All operations were carried out by experienced orthopedic trauma surgeons. Primary outcome measures were rate of implant failure (cut out) and surgical complications (hematoma, infection). Secondary outcome measures were Hb-difference, length of hospital stay and mortality.

RESULTS

Overall, 221 patients were included in the study. 113 were treated with FNS, 108 with DHS. Mean age was 69 ± 14 years. There were 17.2% Garden I, 47.5% Garden II, 26.7% Garden III and 8.6% Garden IV fractures. No difference between the groups for age, body mass index (BMI), Charlson comorbidity index (CCI), time to surgery, Pauwels and Garden classification, rate of optimal blade position or tip apex distance was found. FNS showed lower pre- to postoperative Hb-difference (1.4 ± 1.1 g/l vs. 2.1 ± 1.4 g/l; p < 0.05), shorter operating time (36.3 ± 11.6 min vs. 54.7 ± 17.4 min; p < 0.05) and hospital stay (8.8 ± 4.3 d vs. 11.2 ± 6.8 d; p < 0.05). Surgical complications (FNS 13.3% vs. DHS 18.4%, p > 0.05), rate of cut out (FNS 12.4% vs. DHS 10.2%, p > 0.05) and mortality (FNS 3.5%; DHS 0.9%; p > 0.05) showed no difference between the groups. Logistic regression showed that poor blade position was the only significant predictor for cut out and increased the risk by factor 7. Implant related infection (n = 3) and hematoma/seroma (n = 6) that needed revision was only seen in DHS group.

CONCLUSION

FNS proved to be as reliable as DHS in all patients with hip fractures. Not the type of implant but blade positioning is still key to prevent implant failure. Still due to minimal invasive approach implant related infections and postoperative hematomas might have been prevented using the FNS.

Internal Fixation Versus Hemiarthroplasty for Nondisplaced Femoral Neck Fractures: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare internal fixation (IF) versus hemiarthroplasty (HA) for elderly individuals (ie, older than 65 years) with nondisplaced (ie, Garden type I or II) femoral neck fracture (FNF).

DATA SOURCE

We searched English literature of MEDLINE, PubMed, and Embase from inception to December 4, 2021.

STUDY SELECTION

Eligibility criteria were randomized controlled trials (RCTs) compared IF versus HA for elderly individuals with nondisplaced FNF. Primary outcomes were Harris hip score (HHS), quality of life per European Quality of Life 5 Dimension (EQ-5D), and mortality. Secondary outcomes were complications, reoperation, intraoperative bleeding, operation duration, and length of hospital stay.

DATA EXTRACTION

Two authors separately extracted data and assessed the risk of bias of the included studies using Cochrane risk-of-bias tool.

DATA SYNTHESIS

Three RCTs yielding 400 patients were enrolled, of which 203 (50.7%) underwent IF. Internal fixation was inferior to HA with respect to 6-month HHS [mean difference (MD) = -8.28 (-14.46, -2.10), P = 0.009] and 1-year EQ-5D [MD = -0.07 (-0.14, -0.00), P = 0.04]. The 2 techniques were comparable regarding length of hospital stay (day), HHS at 1 and 2 years, EQ-5D at 2 years, and mortality. IF was inferior to HA in implant-related complication [20.1% vs. 6.0%, relative risk (RR) = 3.18 (1.72, 5.88), P = 0.0002] and reoperation rate [20.1% vs. 6.0%, RR = 3.30 (1.79, 6.08), P = 0.0001]. Hemiarthroplasty had a greater blood loss (mL) [MD = -138.88 (-209.58, -68.18), P = 0.001] and operation duration (min) [MD = -23.27 (-44.95, -1.60), P = 0.04] compared with IF.

CONCLUSION

HA is the preferred technique for nondisplaced FNF if early recovery, higher mobility, and better quality of life are priorities. The choice of fixation should be weighed on an individual patient level.

LEVEL OF EVIDENCE

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

Early Surgical Care of Anticoagulated Hip Fracture Patients Is Feasible-A Retrospective Chart Review of Hip Fracture Patients Treated with Hip Arthroplasty within 24 Hours

Anticoagulative medication such as antiplatelet drugs (PAI, acetylsalicylic acid and direct platelet aggregation inhibitors), vitamin-K-antagonist Warfarin (VKA) or direct oral anticoagulants (DOAC) are common among hip fracture patients, and the perioperative management of these patients is a rising challenge in orthopaedic trauma. Our objective was to determine the effect of oral anticoagulation in patients receiving early endoprosthetic treatment within 24 h after their admission. For the period from 2016 to 2020, a retrospective chart review of 221 patients (mean age 83 ± 7 years; 161 women and 60 men) who were treated either with hemi- (n = 209) or total hip arthroplasty (n = 12) within 24 h after their admission was performed. We identified 68 patients who took PAI, 34 who took DOAC and 9 who took VKA medications. The primary outcome measures were the transfusion rate and the pre- and postoperative haemoglobin (Hb) difference. The secondary outcome measures were the in-patient mortality and the rate of postoperative haematomas that needed operative treatment. A logistic/ordinal regression was performed considering the related variables to prevent cofounding occurring. The mean time to surgery was significantly longer for the DOAC and VKA groups when they were compared to the controls (none 14.7 ± 7.0 h; PAI 12.9 ± 6.7 h; DOAC 18.6 ± 6.3 h; VKA 19.4 ± 5.5 h; p < 0.05). There was no difference in the preoperative Hb level between the groups. Overall, 62 patients (28%) needed blood transfusions during the in-patient stay with an ASA classification (p = 0.022), but the type of anticoagulative medication was not a significant predictor in the logistic regression. Anticoagulation with DOAC and grouped surgery times were positive predictors for a higher Hb difference in the patients who did not undergo an intraoperative blood transfusion (n = 159). Postoperative haematomas only occurred in patients taking anticoagulative medication (four cases in PAI group, and three cases in DOAC group), but the logistic regression showed that the anticoagulative medication had no effect. The in-patient mortality was significantly influenced by a high ASA grade (p = 0.008), but not by the type of anticoagulative medication in patients who were treated within 24 h. We conclude that the early endoprosthetic treatment of the anticoagulated hip fracture patient is safe, and a delayed surgical treatment is no longer justifiable.

The use of the femoral neck system (FNS) leads to better outcomes in the surgical management of femoral neck fractures in adults compared to fixation with cannulated screws: A systematic review and meta-analysis

BACKGROUND

Intracapsular femoral neck fractures are challenging to treat, with outcomes depending on the quality of reduction, and the stability of fixation. Cannulated cancellous screws (CCS) are the most commonly used implants to fix these fractures, but failure rates are significant. The recently introduced femoral neck system (FNS) may be a better option than CCS fixation and this review attempts to compare the results.

METHODS

Four electronic databases were searched for eligible articles that had comparative data on the outcomes of fixation of adult femoral neck fractures with FNS and CCS. Data on various outcome parameters were collected. Meta-analysis was conducted using a random-effects model with 95% confidence intervals.

RESULTS

Eight studies with 509 cases having a mean age of 50.8 years were included for final analysis. FNS was found to be associated with significantly reduced complication rates (p < 0.001), decreased incidence of postoperative femoral neck shortening (p < 0.001), quicker time to fracture union (p = 0.002), and better functional outcome scores (p < 0.001) compared to cannulated screws. FNS was also associated with a shorter operating time (mean difference 6.65 min) although not statistically significant (p = 0.24). CCS group had significantly reduced mean blood loss (p < 0.001).

CONCLUSION

The available literature supports FNS as a better option for adult femoral neck fractures, with a lower complication rate, quicker union, and better clinical outcomes.

LEVEL OF EVIDENCE

Level 3.

Femoral neck system versus cannulated screws for fixation of femoral neck fracture in young adults: a systematic review and meta-analysis

PURPOSE

Femoral neck fracture treatment in young adults remains controversial. Cannulated screws (CS) and femoral neck system (FNS) are well-accepted methods for femoral neck fracture treatment; however, these methods are associated with complications. This meta-analysis aimed to evaluate the relative safety and effectiveness of CS and FNS for treating young patients with femoral neck fractures.

METHODS

We searched the following sources for studies that compared CS and FNS fixation: Cochrane library, Embase, PubMed, Web of Science, Wanfang data, China National Knowledge Infrastructure, China Biology Medicine disc, and Chinese Science and Technology Journals. The outcomes were surgical and prognostic results and complications.

RESULTS

This meta-analysis included eight studies. The pooled results revealed that the two fixation methods were similar in terms of the operation time, length of hospital stay, healing time, intraoperative blood loss, non-union, femoral head necrosis, and internal fixation cut-out. Compared with CS fixation, FNS fixation required fewer intraoperative fluoroscopies and had better Harris Hip Score, earlier weight-bearing, lower number of total complications, lesser femoral neck shortening, and lesser extent of nail retreat.

CONCLUSION

FNS fixation outperforms CS fixation in terms of intraoperative fluoroscopies, Harris Hip Score, and morbidity in young patients with femoral neck fractures. Clinicians should consider FNS as a first choice in treating femoral neck fracture in young adults, except where this approach is contraindicated.

Femoral neck system reduces surgical time and complications in adults with femoral neck fractures: A systematic review and meta-analysis

PURPOSE

Femoral neck fractures (FNF) in adults are conventionally managed with surgical options. This paper is aimed to assess the safety, and functional outcomes of the novel Femoral neck system (FNS) for FNF treatment in adult population.

METHODS

An organized quest of four literature databases (PubMed, Scopus, Web of Science, and Cochrane Library) was performed on March 1, 2022 using the term "femoral neck system". Fixed or random-effect meta-analysis was used to analyse the outcome measures after selecting relevant studies and assessing their quality. Heterogeneity was considered when calculating pooled effect sizes and 95% confidence ranges.

RESULTS

On comparing FNS with cannulated cancellous screws (CCS) or other methods, in a total of 762 patients (351 FNS and 411 CCS) in the 11 comparative studies considered for meta-analysis, blood loss was pointedly higher overall in the FNS group, mean difference 115.77 ml; 95% CI 3.11 ml, 28.42 ml; test of overall effect: z = 1.68, p = 0.09); with considerable heterogeneity. However, in the FNS group the operative time was substantially lower (Mean difference -7.91 min; 95% CI -15.01, -0.80; test of overall effect: z = 2.18, p = 0.03, with marked heterogeneity). Moreover, complications such as infections, non-union, osteonecrosis, implant cut-out were significantly lower in the FNS group with a Mantel Haenszel Odds ratio of 0.20 (95% CI 0.12, 0.34: Z = 6.01, p < 0.0001).

CONCLUSION

Keeping in mind the heterogenicity of the studies, -management of adult patients with FNF with FNS can provide results comparable to traditional fixation methods with significantly lower rate of complications.

Neck of femur fractures treated with the femoral neck system: outcomes of one hundred and two patients and literature review

Introduction

The recently developed femoral neck system (FNS) for treatment of femoral neck fractures (FNF), comprises theoretical biomechanical advantages compared to other implants. The aim of this study was to validate the safety and to report outcomes of patients treated with the FNS.

Method

A retrospective multicentric analysis of patients treated by FNS with a minimum of three months of follow-up. Details analysed from three medical centres were operative duration, estimated blood loss, initial hospitalisation duration, fixation quality as well as complications and reoperation rate. Patients who had revision surgery were compared to all other patients to identify risk factors for failure. In addition, a literature review was performed to analyse data on FNS clinical implementation and patient’s outcomes. The two data sets were combined and analysed.

Results

One-hundred and two patients were included in this study cohort with an average follow-up of seven months (range 3–27). Ten papers were included in the literature review, reporting data on 278 patients. Overall, 380 patients were analysed. Average age was 62.6 years, 52% of the fractures were classified as Gardens 1–2. Overall, the revision rate was 9.2% (14 patients diagnosed with cut-out of implant, 10 with AVN, 8 with non-union and 8 with hardware removal). For the 102 patients in the cohort risk factors for reoperation included patients age, surgeon seniority and inadequate placement of the implant.

Conclusion

This study shows that FNS is a safe treatment option for FNF. Intra-operative parameters and failure rates are comparable to previously reported rates for this implant and other frequently used implants.

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

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