Scintimetric evaluation of nailed femoral neck fractures with special reference to type of osteosynthesis

Parallel and non-parallel cannulated screw fixation complications in femoral neck fractures: A systematic review and meta-analysis

BACKGROUND

Since its introduction in the early 1960s, the multiple cannulated screw fixation method has been developed for use in femoral neck fractures (FNFs); however, the parallelism of screws remains controversial.

MATERIALS AND METHODS

MEDLINE, Embase, and the Cochrane Library were systematically searched for studies published before June 2, 2020, that compared the use of parallel and non-parallel screw fixation for the treatment of FNF. The pooled analysis was designed to identify differences between the two groups and focused on postoperative complications, including fracture nonunion and osteonecrosis of the femoral head (ONFH).

RESULTS

Over four studies, we enrolled 445 patients, including 195 patients with fixed FNF with parallel trajectory screws and 250 patients with fixed FNF with non-parallel screws. The pooled analysis showed no difference in the nonunion rates (odds ratio (OR)=0.91; 95% confidence interval (CI), 0.24-3.44; p=0.89) and no significant difference in the incidence of ONFH between parallel and non-parallel screw fixation (OR=0.74; 95% CI: 0.21-2.63; p=0.64).

CONCLUSIONS

The results of this meta-analysis reveal that screw parallelism in multiple cannulated screw fixation of FNF has no relationship with either the fracture nonunion rate or the incidence of postoperative ONFH.

LEVEL OF EVIDENCE

III; meta-analysis.

Efficiency of an implant: new criterion of objective assessment of implants for osteosynthesis of femoral neck fracture

PURPOSE

In line with several designs for osteosynthesis of femoral neck fracture (FNF), their effectiveness is still estimated by the results of biomechanical and clinical trials, finite element method (FE). But surgeons require the criteria which would define their properties in advance and allow improve the results of treatment.

METHODS

When new implant (NI) is being designed, we developed such criterion - index efficiency of an implant (IEI) - and performed mathematical comparative researches of properties of NI with the known designs. We analyzed the results of comparative clinical trials on treatment of FNF with various implants considering their IEI.

RESULTS

Analysis showed that results of comparative clinical trials with the use of various implants for osteosynthesis FNF completely correlated to their IEI; IEI of the NI two to three times exceeds IEI of all known designs, and the destruction percentage of a bone tissue is two to three times less when it is applied.

CONCLUSION

The offered IEI can be used for designing new implants and allows improving the results of treatment of patients with FNF by optimizing the choice of implant for osteosynthesis.

Anteromedial femoral neck plate with cannulated screws for the treatment of irreducible displaced femoral neck fracture in young patients: a preliminary study

BACKGROUNDS

Although most displaced femoral neck fractures of young patients can be repositioned successfully by closed reduction, there are still some can not repositioned successfully by this way and open reductions are required. This type of fracture was defined as irreducible displaced femoral neck fracture in this study. The purpose of this study was to introduce a new technique using anteromedial femoral neck plate with cannulated screws fixation by open reduction for the treatment of irreducible displaced femoral neck fractures in young patients.

METHODS

Totally 26 patients with irreducible displaced femoral neck fracture treated by this technique were retrospectively reviewed. This technique included three major steps: open reduction of femoral neck fracture was performed via the modified anterior approach of hip joint, anteromedial femoral neck plate was fixed to the femoral neck, and two cannulated compression screws were inserted in the femoral neck inside.

RESULTS

All patients were followed up with an average of 18months (range 12-30 months). Radiological and clinical outcomes were evaluated. The fracture union was achieved in 24 patients (92.3%) with an average duration of 4.5 months (range 3.8-10 months). Nonunion was not observed in all cases. Avascular necrosis of femoral head was identified in two patients (7.7%). Clinical outcomes of 24 hips with satisfactory union were evaluated by the Harris Hip Scores (HHS), excellent outcomes were achieved in 20 cases (HHS ≧ 90), fair outcomes in 3 cases (80 ≦ HHS < 90), and poor outcome in 1 case (HHS < 80).

CONCLUSIONS

Anteromedial femoral neck plate with cannulated screws fixation by open reduction is an alternative therapeutic method for the irreducible displaced femoral neck fracture in young patients, with low incidence of complications including nonunion and avascular necrosis.

Early Roentgenological Grading of Femoral Shortening is Correlated to the Late Outcome after Femoral Neck Fractures

Using orthoradiography, the distance between the centre of the femoral head and the intercondylar notch was assessed at regular intervals in 144 patients who were followed for a 2-year period after osteosynthesis of a femoral neck fracture. Late complications, such as segmental collapse and non-union, occurred in 27% of the patients. The degree of femoral shortening was significantly correlated to the incidence of late complications. At 1 month, femoral shortening of more than 5 mm was observed in 85% of patients who developed late complications, and in only 5% of patients without such complications. Thus, the observation of a shortening of more than 5 mm predicted a greater than 6-fold increase of the incidence of late complications. The prognostic accuracy of this observation 1 month after treatment was 92%.

Comparative study of multiple cancellous screws versus sliding hip screws in femoral neck fractures of young adults

PURPOSE

Both cannulated cancellous screw (CCS) and sliding hip screw (SHS) are used in femoral neck fracture fixations, but which is superior is yet to be determined. This study was aimed to compare the clinicoradiological outcome of femoral neck fracture treated with SHS or CCS in young adults.

METHODS

Adults (16e60 years) with femoral neck fracture were divided into Group 1 fixed with SHS and Group 2 fixed with three CCS after closed reduction. Pain relief, functional recovery and postoperative radiographs at 6 weeks, 3 months, 6 months and then yearly for upto 4 years were analyzed.

RESULTS

Group 1 (n=40) achieved radiological union at mean of 7.6 months, with the union rate of 87.5% (n=35), avascular necrosis (AVN) rate of 7.5% (n=3) and mean Harris Hip Score (HHS) of 86.15 at the end of 4 years. In Group 2 (n=45) these parameters were union at 7.1 months, union rate of 82.22% (n=37), AVN rate of 6.67% (n=3) and HHS of 88.65. Comparative results were statistically insignificant.

CONCLUSION

There is no significant difference in clinicoradiological outcome between the two implants.

Low failure rate by means of DLBP fixation of undisplaced femoral neck fractures

Background

This study evaluated the clinical results of a new implant in the internal fixation of undisplaced femoral neck fractures.

Method

Irrespective of their age, 149 patients with undisplaced (Garden I and II) femoral neck fractures were included in a prospective multicentre clinical cohort study and were treated by internal fixation by means of the Dynamic Locking Blade Plate (DLBP). The mean age was 69 years and the follow-up at least one year.

Results

The DLBP fixation resulted in 6 out of 149 failures caused by AVN (2x), non-union (2x), loss of fixation (3x) or combination of these.

Conclusion

The fixation of undisplaced femoral neck fractures by the DLBP resulted in a low failure rate of 4 %.

The dynamic locking blade plate, a new implant for intracapsular hip fractures: biomechanical comparison with the sliding hip screw and Twin Hook

Internal fixation of intracapsular hip fractures results in a high failure rate with non-union and avascular necrosis being the two most important complications. In order to prevent these possible complications treatment should consist of an anatomical reduction and stable fixation by insertion of a low volume, dynamic implant, providing angular and rotational stability to the femoral head. According to these principles a new implant, the dynamic locking blade plate (DLBP) was designed for the fixation of intracapsular hip fractures. We performed a biomechanical analysis in synthetic bone to compare the rotational stability and cut out resistance of the DLBP with a conventional sliding hip screw (SHS) and the more recently developed Twin Hook. The rotational stability of the DLBP proved to be three times higher than the rotational stability of a SHS and two times higher than the Twin Hook. There was no major difference in cut out resistance between the different implants. The design of the DLBP and possible advantages with regard to the healing of an intracapsular hip fracture are discussed.

Dementia after delirium in patients with femoral neck fractures

OBJECTIVES

To investigate whether delirium in older patients with femoral neck fractures is associated with an increased risk of developing dementia and a higher mortality rate.

DESIGN

A 5-year prospective follow-up study.

SETTING

Department of Orthopedic Surgery at the University Hospital in Umeå, Sweden.

PARTICIPANTS

Seventy-eight nondemented patients aged 65 and older operated on for femoral neck fractures were followed for 5 years.

MEASUREMENTS

The patients were assessed using the Organic Brain Syndrome (OBS) Scale pre- and postoperatively. Medical and social data were collected from the patients, their caregivers, and medical records, and the survivors were visited and assessed with the OBS Scale and the Mini-Mental State Examination in their homes 5 years after the fracture.

RESULTS

Thirty of 78 (38.5%) nondemented patients with a femoral neck fracture developed dementia within a 5-year period. Twenty of 29 (69%) who were delirious postoperatively developed dementia, compared with 10 of 49 (20%) who were not delirious during their hospital stay (P <.001). Twenty-one (72.4%) of those with postoperative delirium died within 5 years, compared with 17 of 49 (34.7%) of those who remained lucid postoperatively (P =.001).

CONCLUSION

Delirium in nondemented femoral neck fracture patients is associated with the development of dementia and a higher mortality rate. Patients with preoperative or postoperative delirium should therefore be assessed not only for the etiology of the delirium but also for any underlying organic brain disorder. Questions that remain unanswered are whether postoperative delirium is a marker of undetected dementia and whether postoperative delirium contributes to the development of dementia.

Delirium before and after operation for femoral neck fracture

OBJECTIVES

The aim of this study was to investigate the differences between preoperative and postoperative delirium regarding predisposing, precipitating factors and outcome in older patients admitted to hospital with femoral neck fractures.

DESIGN

A prospective clinical assessment of patients treated for femoral neck fractures.

SETTING

Department of orthopedic surgery at Umeå University Hospital, Sweden.

PARTICIPANTS

One hundred one patients, age 65 and older admitted to the hospital for treatment of femoral neck fractures.

MEASUREMENTS

The Organic Brain Syndrome (OBS) Scale.

RESULTS

Thirty patients (29.7%) were delirious before surgery and another 19 (18.8%) developed delirium postoperatively. Of those who were delirious preoperatively, all but one remained delirious postoperatively. The majority of those delirious before surgery were demented, had been treated with drugs with anticholinergic properties (mainly neuroleptics), had had previous episodes of delirium, and had fallen indoors. Patients who developed postoperative delirium had perioperative falls in blood pressure and had more postoperative complications such as infections. Male patients were more often delirious both preoperatively and postoperatively. Patients with preoperative delirium were more often discharged to institutional care and had poorer walking ability both on discharge and after 6 months than did patients with postoperative delirium only.

CONCLUSIONS

Because preoperative and postoperative delirium are associated with different risk factors it is necessary to devise different strategies for their prevention.

Internal fixation implants for intracapsular proximal femoral fractures in adults

BACKGROUND

Numerous different implants with screws, pins and side plates have been used for the internal fixation of intracapsular hip fractures.

OBJECTIVES

To determine from randomised trials which implant is superior for the internal fixation of intracapsular proximal femoral fractures.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group specialised register. The date of the most recent search was December 2000.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing different implants for the internal fixation of intracapsular hip fractures in adults.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality, by use of a ten item scale, and extracted data. Additional information was sought from trialists. After grouping by implant type, comparable groups of trials were subgrouped and where appropriate, data were pooled using the fixed effects model.

MAIN RESULTS

Twenty-seven studies involving 5269 participants (5274 fractures) were included in the study. Considerable variation in the quality of methodology between studies was found and biases due to familiarity with some of the implants were noted. None of the implants tested were found to be significantly superior for any of the outcome measures related to fracture healing complications or mortality. The sliding hip screw was found to take longer to insert and to have an increased operative blood loss compared with multiple screws or pins.

REVIEWER'S CONCLUSIONS

No clear conclusions can be made on the choice of implant for internal fixation of intracapsular fractures from the available evidence within randomised trials.

Pathophysiology of delayed healing

Delayed union represents an ongoing failure of initial fracture management. It still occurs partly because the precise reason why a patient's fracture does not heal frequently is unknown. This article aims to outline the limited material available on the pathophysiology of delayed healing. The systemic status of the patient, local limb status before injury, the nature of the traumatic injury, local host response to the injury, potential negative impact of orthopaedic fracture care, and pharmacologic variables are considered.

The effect of femoral neck fractures on femoral head blood flow

Treatment of femoral neck fractures remains a significant clinical challenge. The choice between femoral head replacement and internal fixation must take into account the patient's age, activity level, degree of osteoporosis, and medical condition. If open reduction and internal fixation is chosen, an understanding of the vascular pathophysiology of femoral neck fractures is helpful to insure the best clinical result. Osteonecrosis of the femoral head and non-union of the femoral neck fracture are the two most common complications following fixation of a femoral neck fracture. The vascular damage from the fracture itself significantly reduces femoral head perfusion. Therefore, a careful and anatomic (or slightly valgus) reduction, followed by rigid fixation with three pins, three screws, or a hip screw construct, is advised. There is experimental and clinical evidence that "emergent" open reduction and internal fixation and capsulotomy may lessen the vascular insult from the femoral neck fracture itself.

Social function after cervical hip fracture. A comparison of hook-pins and total hip replacement in 47 patients

47 patients with a cervical hip fracture Garden 3 or 4 and fully ambulatory before the fracture, were randomized to either fixation with Hansson hook-pins (24 patients, median age 79 years) or to a Charnley hip replacement (23 patients, median age 80 years). The patients were followed for 2 years. Social function was evaluated using a standard questionnaire. There were no postoperative deaths and no significant differences in hospital stay. 9/24 patients treated with hook-pins developed healing complications and 2 dislocations occurred in the THR group. After 1 and 2 years, fewer patients treated with hip replacement used outdoor walking aids; they were also more likely to do their own shopping. Hip replacement is a good choice when treating healthy older people with displaced cervical hip fractures, when primary mortality is expected to be low and the risk of healing complications after nailing is high.

Fixation of femoral neck fracture. A randomized 2-year follow-up study of hook pins and sliding screw plate in 222 patients

We compared fixation with hook pins or sliding screw plate in a prospective randomized study of 222 patients with a cervical hip fracture. Radiographic evidence of early redisplacement, nonunion, or late segmental collapse was found in 43 of 122 patients operated on with two hook pins and in 40 of 100 patients operated on with the sliding screw plate. According to the actuarial method, the failure rate after 2 years was 38% with hook pins and 46% with screw plates, which not is a significant difference. Due to early redisplacement, reoperation with an endoprosthesis was performed within 0.5 (2) years in 11 (22) patients in the hook-pin group and in 4 (17) patients in the sliding-screw plate group.

Function after primary hemiarthroplasty and secondary total hip arthroplasty in femoral neck fracture

Four to 12 years after primary treatment of femoral neck fracture with hemiarthroplasty in a group of Finnish patients and secondary total hip arthroplasty as a salvage procedure for healing complication after primary osteosynthesis in a group of Swedish patients, function was classified and the Nottingham Health Profile questionnaire was applied. The two groups were comparable with regard to age, sex, and social status. The patients with secondary total hip arthroplasty used walking aids to a lesser extent than the patients with hemiarthroplasty and experienced less problems in several aspects of life. Walking ability was considered unchanged, compared to prefracture, to a larger extent in the secondary total hip arthroplasty group. Thus, secondary total hip arthroplasty in patients with healing complication following primary osteosynthesis gives better long-term functional capacity than that obtained with a primary hemiarthroplasty.

Bone mineral content and fixation strength of femoral neck fractures. A cadaver study

We measured the bone mineral content (BMC) of 21 human femoral autopsy specimens using Radiographic Attenuation Technique (RAT). The specimens were then tested for stiffness in a material-testing machine. Osteosynthesis was performed after medial femoral neck osteotomy, using 1 of 3 different pinning methods: 2 hook pins (LIH), 2 cannulated screws (Uppsala), and 3 cannulated screws (CHP). The specimens were allocated to each method by grouping them in triplets with similar BMC. Cyclic loading at 500-1000 N and 1 Hz was performed during 50 minutes. The amount of axial compression during loading was measured. Finally, loading to failure was done and post-fixation stiffness and ultimate compression strength recorded. With one exception, all cases failed where the BMC was less than 0.4 g/cm2. No differences between the methods of osteosynthesis were found. The fixation strength was mostly dependent on the strength of the bone, i.e., the degree of osteoporosis.

Implant/bone constructs in femoral neck osteotomy. An autopsy study

Previous studies have suggested that three rather than two screws may give better results in the treatment of femoral neck fractures. In the present study, the strength of various screw/bone constructs in femoral neck osteotomy was analyzed. Transverse osteotomies on 65 cadaver femora were fixed with two or three screws of two types: one with a shank diameter of 6 mm and thread diameter of 8 mm, and a prototype screw with equal shank and thread diameter of 7 mm. The femoral heads were subjected to static and cyclic loads in the one-legged stance position. Single-energy quantitative computed tomography measurements were correlated to load. The two experimental models resulted in different patterns of failure of the bone/implant constructs, otherwise the results were similar. Three of the prototype screws gave the strongest construct, while two of the other screw type were stronger than three. The explanations for the diverging properties of the different bone/implant constructs may be that large threads destroy too much of the bone trabeculae, and that screw threads larger than the shank may destroy the drill canal and produce an unstable situation compared with screws with equal shank and thread diameter.

Prediction of fixation failure in femoral neck fractures. Comminution and avascularity studied in 40 patients

We performed 99m-Tc diphosphonate scintimetries in 40-elderly patients who had undergone screw fixation for a recent subcapital femoral fracture and analyzed their preoperative radiographs. The data were subjected to a logistic regression analysis. Both comminution of the calcar femorale and reduced scintimetric uptake were predictive for failure of the osteosynthesis during the first year. Fracture comminution was more predictive for early failures during 3 months and scintimetry for the later failures.

Factors predicting healing complications in femoral neck fractures. 138 patients followed for 2 years

We have previously studied the radiographic outcome of femoral neck fracture osteosynthesis with either two hook-pins or a four-flanged nail performed by a small group of surgeons with special interest in the methods. In 138 femoral neck fractures a backwards stepwise logistic regression analysis was used to study the significance of preoperative fracture-related factors, intraoperative factors and the osteosynthesis. The development of non-union/redisplacement and segmental collapse of the femoral head was influenced by fracture displacement (P 0.001) and method of osteosynthesis (P 0.007). The postoperative scintimetric ratio was influenced by the method of osteosynthesis (P 0.0003), fracture displacement (P 0.004) and by the presence of a posterior fragment (P 0.03). Reduction of the fracture and positioning of the osteosynthesis were to a large extent within the accepted limits. This may explain why the previously well documented negative effects of malpositioning of the osteosynthesis and inferior reduction were not demonstrated to influence the rate of healing-complications. We conclude that neither patient age, sex nor preoperative fracture variables, with the exception of the extent of fracture displacement, can be used to predict radiographic healing-complications in femoral neck fractures.

Femoral neck fracture fixation with hook-pins. 2-year results and learning curve in 626 prospective cases

We performed a prospective 2-year follow-up study of 626 consecutive femoral neck fractures treated with closed reduction and hook-pin fixation in all cases. The woman:man ratio was 2.9:1, the displaced:undisplaced fracture ratio 2.6:1. Mean patient age was 78 (18-100) years. The first 476 fractures were operated on by one of six surgeons with special interest in the technique, while the remaining operations were performed by any of the 35 surgeons in the department, all specialists in orthopedic surgery. Mortality within two years was 31 percent. Healing complications (redisplacement, nonunion or segmental femoral head collapse) in the total material/survivors only were for undisplaced fractures 5/7 percent, for displaced fractures 30/41 percent and for the total material 23/32 percent. According to life-table analysis, the complication rate in the total material at two years was 24 percent. The rate of secondary arthroplasty for healing complications was 13/19 percent. For displaced fractures, as well as for the total material, the group of specially interested surgeons had better results than the department as a whole.

Function of the hip after femoral neck fractures treated by fixation or secondary total hip replacement

Two matched groups of 28 patients each, with femoral neck fractures treated by primary internal fixation or by secondary total hip replacement after a complication of primary treatment, were evaluated and compared five years or more after primary pin fixation or secondary total hip replacement. The Nottingham Health Profile questionnaire was sent and returned by mail and the patient groups were matched with regard to age, sex, health, and social situation. Patients with healed fractures had less problems with sleep, housework and hobbies, and thus functioned better than patients who had required a secondary total hip replacement.

A geriatric-anesthesiologic program to reduce acute confusional states in elderly patients treated for femoral neck fractures

The aim of this study was to evaluate the effect of a geriatric-anesthesiologic intervention program for the prevention and treatment of acute confusional states (ACS) in elderly patients treated for femoral neck fractures. The intervention program was based on the results of previous prospective studies in similar patient populations. The outcome of the intervention, comprising 103 patients, was compared with that of an earlier study comprising 111 patients. The intervention program consisted of pre- and post-operative geriatric assessments, oxygen therapy, early surgery, prevention and treatment of peri-operative blood pressure falls and treatment of post-operative complications. The incidence of ACS was lower, 47.6%, in the intervention study compared with 61.3% (P less than 0.05) in the control study. Furthermore, the ACS that occurred in the intervention study was less severe and of shorter duration than that in the control study. The incidence of post-operative decubital ulcers, severe falls, and urinary retention was also lower. The mean duration of orthopedic ward stay was 17.4 days in the control study and 11.6 days in the intervention study (P less than 0.001). It can be concluded that the intervention program reduced the incidence, severity, and duration of ACS which resulted in a shortened orthopedic ward stay.

Redisplacement of nailed femoral neck fractures. 4-year follow-up of 110 cases

In 110 femoral neck fractures, we measured the articulotrochanteric distance and the anteroposterior position of the femoral head, preoperatively, postoperatively, and at a minimum follow-up of 2 years. In displaced fractures the size of the displacement could not be used to predict future incidence of fracture redisplacement or femoral head necrosis.

Internal fixation of femoral neck fractures in Parkinson's disease. 32 patients followed for 2 years

32 patients, suffering from Parkinson's disease, had internal fixation of femoral neck fractures. In 24 displaced fractures, 6 nonunions and 3 segmental collapses were seen; and in 8 undisplaced fractures, 1 case of segmental collapse was diagnosed. Healing complications were thus seen in one third. Total hip replacement for healing complication was performed in 3 of 32 patients. 9 patients died within 2 years. No difference in the rate of healing or mortality was detected compared with hip fracture patients without Parkinson's disease. Our study does not support primary arthroplasty for femoral neck fracture in patients with Parkinson's disease.

Function after hook-pin fixation of femoral neck fractures. Prospective 2-year follow-up of 191 cases

Totally, 191 consecutive patients with femoral neck fractures during 1984 and 1985 had internal fixation with hook-pins and were prospectively investigated. Within 2 years, 62 patients had died and 47 had developed healing complications, 30 of whom had been treated with total hip replacement. Thus, 82 healed without complication. Forty-one of 47 patients without other handicaps affecting their walking ability considered their gait as good as it was preoperatively; 45 used no walking aids or a cane. Nine of 35 patients with a nonfracture-related disease affecting their walking ability managed to walk with or without a cane; 13 considered their walking ability unaltered compared with their prefracture state. Three of 82 patients complained of pain on walking and 2 of pain at rest. All but 1 could flex their hip 90 degrees or more. We believe that the function after internal fixation of cervical hip fracture with uncomplicated healing is superior to that achieved by primary hip replacement; primary replacement is recommended only in rheumatoid patients with displaced fractures.

Stability of femoral neck fractures. A postoperative roentgen stereophotogrammetric analysis

Using roentgen stereophotogrammetric analysis, the postoperative stability of femoral neck fractures was measured in 16 patients. During the first day after internal fixation, before weight bearing, the center of the femoral head moved on an average 1.5 mm (total translation) in six undisplaced fractures and 3.7 mm in 10 displaced fractures, which was about one third of the fracture movement during the first postoperative month. Three undisplaced fractures displayed a rotatory instability, mainly after weight bearing had begun. Five of the displaced fractures showed maximal rotatory displacement during the first postoperative day. The recorded fracture movements before weight bearing may question the rationale of peroperative mechanical compression.

Stability of femoral neck osteosynthesis. Comparison of fixation methods in cadavers

Fixation of vertical femoral neck osteotomies in 50 cadavers was performed with either von Bahr screws or a sliding hip compression screw. One specimen from each pair of femora was used for the osteotomy, the other serving as an intact control. At 0.05 r of torsion the load-deformation test showed that three von Bahr screws provided the strongest fixation, and this was confirmed by the the ultimate torsional moment test. Regardless of positioning, even two von Bahr screws were stronger than the sliding compression screw with or without an additional lag screw. The results indicate that the best torsional stability in femoral neck fractures can be obtained with three 5.5-mm screws.

Nailing of femoral neck fracture. Clinical and sociologic 5-year follow-up of 510 consecutive hips

In a retrospective population-based study, 510 consecutive cervical hip fractures treated by internal fixation with a spring-loaded four-flanged nail, early weight bearing, and social rehabilitation were examined at 5 years after primary nailing. Six (1.6 percent) deep infections occurred. After a new trauma, seven fractures through the nail entrance were seen. Mortality at 2 years was 32 percent and at 5 years 53 percent. With a program for active rehabilitation, 80 percent of the survivors coming from independent living returned to this and remained there. The frequency of reoperations in patients below age 70 years was twice as high as in those over 70. Secondary arthroplasty was performed in 6 percent of the 129 undisplaced fractures and in 25 percent of the 381 displaced fractures. Totally, 67 percent of the fractures had no secondary procedure, not even nail extraction.

Acute confusional states in elderly patients treated for femoral neck fracture

The aims of this study were to estimate the incidence of acute confusional state (ACS), its predisposing factors and consequences in 111 consecutive patients operated for fractured neck of the femur. The incidence of ACS was 61 percent and the predicting factors were old age and dementia. Drugs with anticholinergic effect, depression, and previous stroke were factors that seemed to be associated with the development of ACS. Ninety-two percent of the patients who had severe perioperative blood pressure drops developed ACS. The consequences of ACS were prolonged ward-stay at the orthopedic department, a greater need for long-term care after discharge, and poor walking ability at discharge and six months after surgery. The confused patients also had more complications, such as urinary problems, feeding problems and decubital ulcers, as compared with the nonconfused patients.

Intraarticular pressure during operation of cervical hip fractures

The intraarticular pressure was measured during nailing of femoral neck fractures in 21 patients. A three-flanged nail or three screws were used randomly. During traction and inward rotation of the leg, the intracapsular pressure increased over diastolic values, but as soon as the lateral cortex was penetrated, the pressure dropped. The hammering of the nail did not increase the intraarticular pressure.

Fixation of displaced femoral neck fractures. A comparison between sliding screw plate and four cancellous bone screws

In a prospective, randomized trial, 104 consecutive patients with displaced femoral neck fractures were allocated either to fixation with a sliding screw plate or 4 ASIF cancellous bone screws. The patients were reexamined at fixed intervals to determine the time of union. The 2-year-cumulated rate of union was 64 per cent in the plate group and 84 per cent in the screw group.

Stability of fixation in femoral neck fractures. Comparison of four fixation devices in vivo and in cadavers

On human cadaveric femora, internal fixation of cervical osteotomies was performed with four different devices. With the use of a lever, a static force was applied through the acetabulum to the osteotomy site. Motion at the osteotomy site was measured by two strain gauges. The compression force necessary to inhibit motion at the osteotomy site during the fixation procedure was measured. This force was lower with a hook pin than with the other devices. During surgery in 12 patients with displaced femoral neck fractures, the forces holding the fracture surfaces together were measured with a dynamometer. The force at which widening of the fracture gap was observed by fluoroscopy was recorded. In seven fractures, the mean compression force was 110 (60-170) N. The remaining five fractures did not open up when pressures of up to 200 N were applied. These forces were always greater than the hook pin forces measured in the cadaver experiments, but often less than the forces obtained with the other devices.

Hip joint pressure after femoral neck fracture

The hip joint pressure in 40 patients with intracapsular femoral neck fractures was measured on the fracture table prior to surgery. All but 1 patient had pressures well below 20 mmHg with the hip unreduced. When the hip was extended and internally rotated, the pressure rose to values exceeding the normal arteriolar pressure in most patients, with a peak pressure of 135 mmHg. In nine of 22 Garden IV fractures, the pressure remained low despite extension and inward rotation. Injection of contrast medium in three of these hips indicated a rupture of the joint capsule. The pressure response to extension and internal rotation was less marked in fractures older than 72 hours. The findings do not support the hypothesis that a hip-joint tamponade is a common etiologic factor for the development of femoral head necrosis following fracture. However, prolonged reduction maneuvers with the hip joint in extension and internal rotation can create intracapsular pressures high enough to temporarily jeopardize the circulation of the femoral head.

Improved operations for femoral neck fracture. A radiographic evaluation

A radiographic investigation was undertaken to determine whether an increased interest in femoral neck fractures improved the operative result. In 1977, all femoral neck fractures were operated on by any of 30 surgeons of the orthopedic department, but in 1981 all fractures were operated on by one of six specially devoted surgeons. Preoperative fracture classification was performed with three parameters and proved equal in the 1977 and 1981 groups of 105 and 114 fractures, respectively. The quality of fracture reduction, determined with four parameters, was improved somewhat. The position of the nail(s), also determined with four parameters, improved considerably. The technical result was better in Garden IV fractures than in Garden III fractures. An increased interest in femoral neck fracture treatment improved reduction and fixation.

Factors influencing the incidence of reoperation after femoral neck fractures

This investigation compares two groups of patients with fractures of the femoral neck: 22 required a further operation and 72 did not. Special attention was paid to osteoporosis, the displacement of the fracture, viability of the femoral head, operative impaction and osteosynthesis with a Thornton nail or three Scand hip pins. There was a significant (p less than 0.01) difference between the two groups with regard to osteoporosis, fracture displacement and viability of the femoral head. Scand hip pins, as compared to Thornton nails, showed a tendency (p less than 0.1) to need a smaller number of reoperations. Operative impaction compared with no impaction showed no difference.

Hip fracture in rheumatoid arthritis

All patients with rheumatoid arthritis, admitted for hip fracture to a regional hospital during a 5-year period, were studied in retrospect. Of 1092 hip fractures, 16 cervical and nine trochanteric fractures occurred in rheumatics. Four cervical fractures were stress fractures. The mean patient age was lower than in a normal hip fracture material and the female predominance more pronounced. Of 14 surviving patients with cervical fractures, three had an uncomplicated 2-year healing, while 11 developed redisplacement, non-union or segmental collapse, in eight cases necessitating hip arthroplasty. Of eight surviving patients with trochanteric fractures, serious complications developed in two: non-union in one and septicaemia in one, necessitating nail extraction 1 week after the primary operation. The complication rate was higher than in an unselected femoral neck fracture material.

Two-year follow-up of femoral neck fractures. Comparison of osteosynthesis methods

For 14 consecutive months, all 152 femoral neck fracture patients greater than or equal to 50 years of age admitted to the Lund University Hospital were operated on with two hook-pins if born on an uneven date and a four-flanged nail if born on an even date. A clinical 2-year follow-up revealed a 35 per cent mortality. Among survivors, radiographic healing complications were seen in undisplaced fractures in 1/13 pinned and 5/14 nailed (p greater than 0.05) and in displaced fractures in 12/36 pinned and 23/32 nailed (p less than 0.01). This outcome correlated well with the early postoperative scintimetry. Reoperation within 2 years had been performed for seven pinned and 19 nailed fractures. In hook-pinning, thus, less than one patient out of 12 needed a reoperation with THR within 2 years. This figure is interpreted as strongly favouring hook-pinning before arthroplasty as the primary procedure in femoral neck fracture.

Internal fixation of femoral neck fractures. Compression screw compared with nail plate fixation

In a prospective, randomized study of femoral neck fracture operations, a newly developed compression-screw device was compared with the McLaughlin nail-plate. One hundred and twenty-eight fractures were treated with the compression screw and 127 with a nail plate. The patients were followed up for 3 years. All undisplaced fractures healed in both groups. Eleven per cent of displaced Garden 3 and 4 fractures did not heal in the compression-screw group compared to 25 per cent in the nail-plate group. Late segmental collapse occurred in 15 per cent of the healed displaced fractures in the compression-screw group, compared to 21 per cent in the nail-plate group. Fixation of femoral neck fractures using the new compression-screw device gave fewer failures without concomitant disadvantages compared to nail plate fixation.

Emission tomography in femoral neck fracture for evaluation of avascular necrosis

Two cases of operated femoral neck fractures are presented, in whom an intact femoral head isotope uptake was found with conventional Tc-MDP scintimetry. In both patients, emission tomography using the rotating slant-hole technique was diagnostic.

Avascular necrosis associated with nailing of femoral neck fracture. Two cases examined pre- and postoperatively by tetracycline and radionuclide tracer techniques

Two patients with femoral neck fractures, one displaced and one undisplaced, are presented. Preoperative intravital staining with tetracycline and Tc-MDP scintimetry both showed intact femoral head circulation while Tc-MDP-scintimetry 1 week after operation showed pronounced circulatory deficiency. Sr85-scintimetry performed at the same time was inconclusive. Segmental collapse was observed radiographically, 8 and 12 months postoperatively. The major vascular injury resulting in avascularity most probably occurred during the procedure of osteosynthesis, and Tc-MDP-scintimetry was found suitable for early postoperative recognition of avascular necrosis in both fractures.

Femoral head vitality after femoral neck fracture. Comparison between pre- and peroperative tetracycline labeling

Using fluorescence microscopy, a ratio between tetracycline labeling of the femoral head and of the greater trochanter was calculated for 370 femoral neck fractures. Sixty-three patients were given tetracycline on admission to hospital and 307 on the operating table after closed reduction. The following results were obtained: Visual grading of labeling correlated well to a distribution analysis based on a morphometric point-wave pattern. No significant difference concerning the degree of labeling between the pre- and peroperative groups was found. A redistribution into groups according to fracture displacement (Garden I-IV) did not alter this fact. In the total material, labeling was significantly better for undisplaced than for displaced fractures. No difference was found between different degrees of displacement. For patients less than 50 years of age, labeling values were significantly lower. Intact femoral head vascularization (ratio greater than or equal to 0.90) was found in less than three per cent of the total material.