Efficacy and complications after delayed fixation of femoral neck fractures in children

Does open or closed reduction with internal fixation reduces the incidence of complications in neck of femur fractures in pediatrics: a meta-analysis and systematic review

The neck of femur fracture (FNF) in children is a rare injury with a high incidence of complications such as avascular necrosis (AVN), coxa-vara and nonunion. The aim of this review is to compare the incidence of complications between open reduction with internal fixation (ORIF) and closed reduction with internal fixation (CRIF) of FNF in children. Two independent reviewers searched EMBASE, MEDLINE, COCHRANE and PUBMED databases from inception until April 2022 according to the preferred reporting items for systematic reviews and meta-analyses guidelines. Studies included comparison of complications between open and closed approaches with fixation of FNF in patients less than 18 years old. Publication bias was assessed using Egger's test while the Newcastle-Ottawa tool was used to assess the methodological quality of the studies. A total of 724 hip fractures from 15 included studies received either ORIF or CRIF. Overall, the rate of AVN was approximately 21.7% without statistical significance between both reduction methods [relative risk (RR) = 0.909, using fixed effect model at 95% confidence interval (CI, 0.678-1.217)]. No significant heterogeneity among AVN studies ( I2  = 3.79%, P  = 0.409). Similarly, neither coxa-vara nor nonunion rates were statistically significant in both treatment groups (RR = 0.693 and RR = 0.506, respectively). Coxa-vara studies showed mild heterogeneity ( I2  = 27.8%, P  = 0.218), while significant publication bias was encountered in nonunion studies ( P  = 0.048). No significant difference in the incidence of AVN, coxa-vara and nonunion between ORIF or CRIF of FNF in children. High-quality studies as Randomised Controlled Trials can resolve the inconsistency and heterogeneity of other risk factors including age, initial displacement, fracture type, reduction quality and time to fixation.

Risk factors related with avascular necrosis after internal fixation of femoral neck fractures in children: a systematic review and meta-analysis

Background

Less than 1% of children develop femoral neck fractures (FNF), making them uncommon. However, they may have dangerous side effects, like avascular necrosis. Even though several risk factors for postoperative avascular necrosis have been identified, there is still debate regarding them. In this investigation, a meta-analysis was performed to examine the potential causes of postoperative avascular necrosis in children with FNF.

Methods

We conducted a thorough literature search to find risk factors for avascular necrosis (AVN) after internal fixation of pediatric FNF. Until December 2022, we searched several databases, including PubMed, Embase, Cochrane Library, Web of Science, CNKI, Orthosearch, and Sinomed. Software Zotero 6.0 and Stata 17.0 were used to organise and synthesise the data. Finally, a sensitivity and publication bias test was carried out.

Results

Our study includes a total of 15 case-control studies involving 814 patients. The risk of postoperative AVN increased with age at fracture encounter (95% CI: 0.64-1.88, P = 0.0003), initial fracture displacement (95% CI: 1.87-9.54, P = 0.0005), and poor fracture reduction (95% CI:1.95-22.34, P = 0.0024) were risk factors for postoperative AVN. There was no significant relationship between gender and postoperative AVN (95% CI: 0.52-1.31, P = 0.41). Conversely, Postoperative AVN and reduction methods have no connection with each other (95% CI: 0.77-2.66, P = 0.25), procedure time (95% CI: 0.43-2.99, P = 0.16), or injury mechanism (95% CI: 0.32-2.26, P = 0.75). The incidence of post-operative AVN varies between Delbet fracture types (95% CI: 0.15-0.31, P < 0.0001), with the overall trend being that the incidence of post-operative AVN is highest for type II, lowest for type IV, and close for types I and III, but it is not clear which type of fracture is the independent risk factor. Funnel plots indicate no significant publication bias.

Conclusions

In line with this study, About 26% of children who underwent surgery for a femoral neck fracture suffered postoperative AVN. The main risk factors for AVN were the child's age, the initial displacement of the fractures, and poorly reduced fractures. The risk of AVN did not significantly correlate with gender, the time of the procedure, reduction methods or the mechanism of injury. The overall trend in the incidence of postoperative AVN for the different Delbet types of fracture is that the incidence of postoperative AVN is highest for type II, lowest for type IV, and close for types I and III, but it is not clear which type of fracture is the independent risk factor.

Postoperative clinical outcome and complications of combined cannulated cancellous screw with Kirschner wire in adolescent femoral neck fractures

Purpose

Fractures of the femoral neck account for less than 1% of pediatric and adolescent fractures. Due to the high incidence of complications, and the age of the patients, the choice of fixation approach remains controversial among orthopedic surgeons. This study aimed to evaluate the postoperative outcomes and complications of femoral neck fracture in adolescents with open physis, following transphyseal fixation using a combined cannulated cancellous screw and Kirschner wire fixation.

Methods

Data of 19 patients aged between 12 and 19 years from January 2010 to January 2021 were retrospectively studied. The follow-up period was 1-11 years (5.83 ± 3.76 years). The variables of interest including demographic and clinical variables [age, BMI, gender, side of injury, fracture classification, operation time, time to surgery, and length of hospital stay (LOS)], postoperative outcomes, and complications (fracture healing time, nonunion, coxa vara, osteoarthritis, avascular necrosis, screw loosening, and femoral shortening) were analyzed. The assessment of the hip function was done on the final follow-up using the Ratliff scoring system.

Results

There was a male predominance of 76%; the mean age was 16.14 ± 1.57 years and the most frequent mechanism of injury was fall from a height. Delbet type II and III were the most encountered. The mean intraoperative time was 54.71 ± 7.85 min, the LOS was 8.34 ± 1.81days, and the time to surgery was 2.60 ± 1.16 days; the fracture healing time was 3.31 ± 1.04 months. The postoperative complications encountered were coxa vara osteoarthritis, spontaneous dislocation, and neck shortening. Clinical assessment revealed good results in 89% of patients and fair results in 11% of patients.

Conclusion

Transphyseal fixation using cannulated cancellous screw combined with Kirschner wire in our patients provided acceptable results. Thus, this approach can be a viable alternative in the management of adolescent femoral neck fracture with open physis.

Open reduction versus closed reduction in internal fixation of displaced femoral neck fracture in children: a systematic review and meta-analysis

BACKGROUND

The quality of reduction is an important factor affecting clinical outcomes for displaced femoral neck fractures (FNFs). However, concerns remain about the invasiveness of open reduction and internal fixation (ORIF) as compared to that of closed reduction and internal fixation (CRIF), and the choice between ORIF and CRIF as an optimal treatment strategy for displaced pediatric FNF remains controversial.

MATERIALS AND METHODS

MEDLINE, Embase, and the Cochrane Library were systematically searched for studies published up to December 22, 2022, that compared ORIF and CRIF techniques for treating FNF in children. Pooled analysis identified differences in surgical outcomes between ORIF and CRIF, especially regarding postoperative complications, such as osteonecrosis of the femoral head (ONFH), nonunion, coxa vara deformity, leg-length discrepancy LLD, and premature physeal closure (PPC).

RESULTS

We included 15 studies with 635 pediatric FNF cases in our review. Of these, 324 and 311 were treated with ORIF and CRIF, respectively. The pooled analysis revealed that no significant differences existed between each reduction technique for ONFH (odds ratio [OR] = 0.89; 95% confidence interval [CI] 0.51-1.56; P = 0.69), nonunion (OR = 0.51; 95% CI 0.18-1.47; P = 0.21), coxa vara deformity (OR = 0.58; 95% CI 0.20-1.72; P = 0.33), LLD (OR = 0.57; 95% CI 0.18-1.82; P = 0.35), and PPC (OR = 0.72; 95% CI 0.11-4.92; P = 0.74).

CONCLUSIONS

Despite concerns about the invasiveness of ORIF, no differences in complications exist between ORIF and CRIF after FNF in children. Therefore, we believe that ORIF should be performed in FNF when the fracture is irreducible by closed manner.

The incidence and risk factors for femoral head necrosis after femoral neck fracture in pediatric patients: a systematic review and meta-analysis

BACKGROUND

The incidence of avascular necrosis (AVN) after pediatric femoral neck fracture (PFNF) in the literature varies widely, and the risk factors associated with AVN after PFNF are controversial. Therefore, this study aimed to accurately investigate the incidence of AVN after PFNF and systematically evaluate and meta-classify their risk factors.

METHODS

A comprehensive search was performed of PubMed, Web of Science, and Embase. The pooled rate and 95% confidence interval (CI) were used to assess the incidence of AVN after PFNF, and pooled odds ratio (OR) were calculated to measure the effect sizes. In addition, we performed subgroup, stratified, and publication bias analyses.

RESULTS

A total of 30 articles were included in our meta-analysis, with 303 AVN cases among 1185 patients. The pooled incidence of AVN after PFNF was 22% (95% CI 18%, 27%). Subgroup analyses indicated Delbet type I-IV fracture incidences with AVN of 45%, 32%, 17%, and 12%, respectively. The incidence of AVN after PFNF in Asia was 19%, lower than in Africa at 36%, Europe at 26%, and North America at 23%. In addition, the larger sample size group and the earlier published literature group showed a higher incidence of necrosis. Stratified analyses showed that patient age and Delbet fracture classification were both important factors affecting AVN after PFNF (OR = 1.61, p = 0.02 and OR = 3.02, p < 0.001, respectively), while the time to treatment was not (OR = 0.9, p = 0.71).

CONCLUSION

The pooled incidence of AVN after PFNF was ~ 22%; furthermore, the available evidence demonstrates that patient age and Delbet type of fracture were important influencing factors of AVN after PFNF.

The Risk of Avascular Necrosis Following the Stabilization of Femoral Neck Fractures: A Systematic Review and Meta-Analysis

Background: Avascular necrosis (AVN) of the femoral head often requires surgical treatment and is often associated with femoral neck fractures. We conducted a systematic review and meta-analysis of recent research on the risk of AVN following the stabilization of fractured femoral neck with implants in PubMed. We assessed the effect of age on AVN incidence among patients aged > 50 and younger, depending on fracture type, Garden stage, Pouwels degree, Delbet stage, and age category. We followed PRISMA guidelines. Relevant studies were defined as research articles describing real-world studies reporting on the risk of AVN following primary surgical fracture stabilization with implants, published between 1 January 2011 and 22 April 2021. Fifty-two papers met the inclusion criteria, with a total of N = 5930 with surgically managed fractures. The pooled mean AVN incidence was significantly higher among patients with displaced fractures (20.7%; 95% CI: 12.8−28.5%) vs. those with undisplaced fractures (4.7%; 95% CI: 3.4−6.0%). No significant correlation was observed between AVN incidence weighted by sample size and time interval from injury to surgery (p = 0.843, R2 = 0.01). In conclusion, the risk of AVN following femoral neck fractures was generally high, especially in patients with displaced fractures. The time from injury to surgery did not correlate with AVN incidence.