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

Surgical interventions for treating intracapsular hip fractures in older adults: a network meta-analysis

BACKGROUND

Hip fractures are a major healthcare problem, presenting a considerable challenge and burden to individuals and healthcare systems. The number of hip fractures globally is rising rapidly. The majority of intracapsular hip fractures are treated surgically.

OBJECTIVES

To assess the relative effects (benefits and harms) of all surgical treatments used in the management of intracapsular hip fractures in older adults, using a network meta-analysis of randomised trials, and to generate a hierarchy of interventions according to their outcomes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Web of Science, and five other databases in July 2020. We also searched clinical trials databases, conference proceedings, reference lists of retrieved articles and conducted backward-citation searches.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs comparing different treatments for fragility intracapsular hip fractures in older adults. We included total hip arthroplasties (THAs), hemiarthroplasties (HAs), internal fixation, and non-operative treatments. We excluded studies of people with hip fracture with specific pathologies other than osteoporosis or resulting from high-energy trauma.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion. One review author completed data extraction which was checked by a second review author. We collected data for three outcomes at different time points: mortality and health-related quality of life (HRQoL) - both reported within 4 months, at 12 months, and after 24 months of surgery, and unplanned return to theatre (at end of study follow-up). We performed a network meta-analysis (NMA) with Stata software, using frequentist methods, and calculated the differences between treatments using risk ratios (RRs) and standardised mean differences (SMDs) and their corresponding 95% confidence intervals (CIs). We also performed direct comparisons using the same codes.

MAIN RESULTS

We included 119 studies (102 RCTS, 17 quasi-RCTs) with 17,653 participants with 17,669 intracapsular fractures in the review; 83% of fractures were displaced. The mean participant age ranged from 60 to 87 years and 73% were women.  After discussion with clinical experts, we selected 12 nodes that represented the best balance between clinical plausibility and efficiency of the networks: cemented modern unipolar HA, dynamic fixed angle plate, uncemented first-generation bipolar HA, uncemented modern bipolar HA, cemented modern bipolar HA, uncemented first-generation unipolar HA, uncemented modern unipolar HA, THA with single articulation, dual-mobility THA, pins, screws, and non-operative treatment. Seventy-five studies (with 11,855 participants) with data for at least two of these treatments contributed to the NMA. We selected cemented modern unipolar HA as a reference treatment against which other treatments were compared. This was a common treatment in the networks, providing a clinically appropriate comparison. In order to provide a concise summary of the results, we report only network estimates when there was evidence of difference between treatments. We downgraded the certainty of the evidence for serious and very serious risks of bias and when estimates included possible transitivity, particularly for internal fixation which included more undisplaced fractures. We also downgraded for incoherence, or inconsistency in indirect estimates, although this affected few estimates. Most estimates included the possibility of benefits and harms, and we downgraded the evidence for these treatments for imprecision.  We found that cemented modern unipolar HA, dynamic fixed angle plate and pins seemed to have the greatest likelihood of reducing mortality at 12 months. Overall, 23.5% of participants who received the reference treatment died within 12 months of surgery. Uncemented modern bipolar HA had higher mortality than the reference treatment (RR 1.37, 95% CI 1.02 to 1.85; derived only from indirect evidence; low-certainty evidence), and THA with single articulation also had higher mortality (network estimate RR 1.62, 95% CI 1.13 to 2.32; derived from direct evidence from 2 studies with 225 participants, and indirect evidence; very low-certainty evidence). In the remaining treatments, the certainty of the evidence ranged from low to very low, and we noted no evidence of any differences in mortality at 12 months.  We found that THA (single articulation), cemented modern bipolar HA and uncemented modern bipolar HA seemed to have the greatest likelihood of improving HRQoL at 12 months. This network was comparatively sparse compared to other outcomes and the certainty of the evidence of differences between treatments was very low. We noted no evidence of any differences in HRQoL at 12 months, although estimates were imprecise. We found that arthroplasty treatments seemed to have a greater likelihood of reducing unplanned return to theatre than internal fixation and non-operative treatment. We estimated that 4.3% of participants who received the reference treatment returned to theatre during the study follow-up. Compared to this treatment, we found low-certainty evidence that more participants returned to theatre if they were treated with a dynamic fixed angle plate (network estimate RR 4.63, 95% CI 2.94 to 7.30; from direct evidence from 1 study with 190 participants, and indirect evidence). We found very low-certainty evidence that more participants returned to theatre when treated with pins (RR 4.16, 95% CI 2.53 to 6.84; only from indirect evidence), screws (network estimate RR 5.04, 95% CI 3.25 to 7.82; from direct evidence from 2 studies with 278 participants, and indirect evidence), and non-operative treatment (RR 5.41, 95% CI 1.80 to 16.26; only from indirect evidence). There was very low-certainty evidence of a tendency for an increased risk of unplanned return to theatre for all of the arthroplasty treatments, and in particular for THA, compared with cemented modern unipolar HA, with little evidence to suggest the size of this difference varied strongly between the arthroplasty treatments.

AUTHORS' CONCLUSIONS

There was considerable variability in the ranking of each treatment such that there was no one outstanding, or subset of outstanding, superior treatments. However, cemented modern arthroplasties tended to more often yield better outcomes than alternative treatments and may be a more successful approach than internal fixation. There is no evidence of a difference between THA (single articulation) and cemented modern unipolar HA in the outcomes measured in this review. THA may be an appropriate treatment for a subset of people with intracapsular fracture but we have not explored this further.

Internal fixation implants for intracapsular hip fractures in older adults

BACKGROUND

Hip fractures are a major healthcare problem, presenting a huge challenge and burden to patients, healthcare systems and society. The increased proportion of older adults in the world population means that the absolute number of hip fractures is rising rapidly across the globe. The majority of hip fractures are treated surgically. This review evaluates evidence for types of internal fixation implants used in joint-preserving surgery for intracapsular hip fractures.

OBJECTIVES

To determine the relative effects (benefits and harms) of different implants for the internal fixation of intracapsular hip fractures in older adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Web of Science, Cochrane Database of Systematic Reviews, Epistemonikos, Proquest Dissertations and Theses, and National Technical Information Service in July 2020. We also searched clinical trials databases, conference proceedings, reference lists of retrieved articles and conducted backward-citation searches.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs comparing implants used for internal fixation of fragility intracapsular proximal femoral fractures in older adults. Types of implants were smooth pins (these include pins with fold-out hooks), screws, or fixed angle plates. We excluded studies in which all or most fractures were caused by specific pathologies other than osteoporosis or were the result of a high energy trauma.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion. One review author extracted data and assessed risk of bias which was checked by a second review author. We collected data for seven outcomes: activities of daily living (ADL), delirium, functional status, health-related quality of life (HRQoL), mobility, mortality (reported within four months of surgery as early mortality, and at 12 months since surgery), and unplanned return to theatre for treating a complication resulting directly or indirectly from the primary procedure (such as deep infection or non-union). We assessed the certainty of the evidence for these outcomes using GRADE.

MAIN RESULTS

We included 38 studies (32 RCTs, six quasi-RCTs) with 8585 participants with 8590 intracapsular fractures. The mean ages of participants in the studies ranged from 60 to 84 years; 73% were women, and 38% of fractures were undisplaced. We report here the findings of the four main comparisons, which were between different categories of implants. We downgraded the certainty of the outcomes for imprecision (when data were available from insufficient numbers of participants or the confidence interval (CI) was wide), study limitations (e.g. high or unclear risks of bias), and inconsistency (when we noted substantial levels of statistical heterogeneity). Smooth pins versus fixed angle plate (four studies, 1313 participants) We found very low-certainty evidence of little or no difference between the two implant types in independent mobility with no more than one walking stick (1 study, 112 participants), early mortality (1 study, 383 participants), mortality at 12 months (2 studies, 661 participants), and unplanned return to theatre (3 studies, 736 participants). No studies reported on ADL, delirium, functional status, or HRQoL. Screws versus fixed angle plates (11 studies, 2471 participants) We found low-certainty evidence of no clinically important differences between the two implant types in functional status using WOMAC (MD -3.18, 95% CI -6.35 to -0.01; 2 studies, 498 participants; range of scores from 0 to 96, lower values indicate better function), and HRQoL using EQ-5D (MD 0.03, 95% CI 0.00 to 0.06; 2 studies, 521 participants; range -0.654 (worst), 0 (dead), 1 (best)). We also found low-certainty evidence showing little or no difference between the two implant types in mortality at 12 months (RR 1.04, 95% CI 0.83 to 1.31; 7 studies, 1690 participants), and unplanned return to theatre (RR 1.10, 95% CI 0.95 to 1.26; 11 studies, 2321 participants). We found very low-certainty evidence of little or no difference between the two implant types in independent mobility (1 study, 70 participants), and early mortality (3 studies, 467 participants). No studies reported on ADL or delirium. Screws versus smooth pins (seven studies, 1119 participants) We found low-certainty evidence of no or little difference between the two implant types in mortality at 12 months (RR 1.07, 95% CI 0.85 to 1.35; 6 studies, 1005 participants; low-certainty evidence). We found very low-certainty evidence of little or no difference between the two implant types in early mortality (3 studies, 584 participants) and unplanned return to theatre (5 studies, 862 participants). No studies reported on ADL, delirium, functional status, HRQoL, or mobility. Screws or smooth pins versus fixed angle plates (15 studies, 3784 participants) In this comparison, we combined data from the first two comparison groups. We found low-certainty evidence of no or little difference between the two groups of implants in mortality at 12 months (RR 1.04, 95% CI.083 to 1.31; 7 studies, 1690 participants) and unplanned return to theatre (RR 1.02, 95% CI 0.88 to 1.18; 14 studies, 3057 participants). We found very low-certainty evidence of little or no difference between the two groups of implants in independent mobility (2 studies, 182 participants), and early mortality (4 studies, 850 participants). We found no additional evidence to support the findings for functional status or HRQoL as reported in 'Screws versus fixed angle plates'. No studies reported ADL or delirium.

AUTHORS' CONCLUSIONS

There is low-certainty evidence that there may be little or no difference between screws and fixed angle plates in functional status, HRQoL, mortality at 12 months, or unplanned return to theatre; and between screws and pins in mortality at 12 months. The limited and very low-certainty evidence for the outcomes for which data were available for the smooth pins versus fixed angle plates comparison, as well as the other outcomes for which data were available for the screws and fixed angle plates, and screws and pins comparisons means we have very little confidence in the estimates of effect for these outcomes. Additional RCTs would increase the certainty of the evidence. We encourage such studies to report outcomes consistent with the core outcome set for hip fracture, including long-term quality of life indicators such as ADL and mobility.

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.

More intramedullary nails and arthroplasties for treatment of hip fractures in Sweden

BACKGROUND AND PURPOSE

The surgical methods for treatment of femoral neck fractures and trochanteric hip fractures vary. We describe the changes in Sweden over the period 1998–2007 and the regional differences in treatment. Patients and methods Data on 144,607 patients were drawn from the National Patient Register.

RESULTS

The proportion of femoral neck fractures treated with arthroplasty increased from 10% in 1998 to 52% in 2007. The use of intramedullary (IM) nails for pertrochanteric fractures increased from 5% to 20%, at the expense of the use of different sliding hip screws. In subtrochanteric fractures, the use of IM nails increased from 32% to 72%. Re-admissions within 180 days due to hip complications were more common after internal fixation for femoral neck fractures than after arthroplasty, and more common after intramedullary nailing of pertrochanteric fractures than after use of sliding hip screws. Treatment varied substantially within Sweden, particularly regarding the use of IM nails.

INTERPRETATION

An increase in arthroplasties reflects an evidence-based treatment rationale for femoral neck fractures, whereas the increase in use of IM nails in pertrochanteric fractures lacks scientific support. The geographic variations call for national treatment guidelines. Further clinical trials are needed to solve the treatment issues regarding per- and subtrochanteric fractures.

Treatment of displaced femoral neck fractures: a randomized minimum 5-year follow-up study of screws and bipolar hemiprostheses in 100 patients

In a randomized study of 100 patients having displaced femoral neck fractures (Garden types 3-4), we compared internal fixation using 2 von Bahr screws (n = 53) with a bipolar Variokopf prosthesis (n = 47) . The duration of surgery was shorter and the blood loss was less in the group with screws. Dislocation of the prosthesis occurred in 7/47 patients, all within 4 months. After a minimum follow-up of 5 years, 34 of 53 patients had been reoperated on in the screw group and 3/47 patients in the prosthesis group. No differences in patient mortality were noted between the groups after 2 or 5 years. The bipolar prosthesis seems to be a suitable alternative for primary treatment of displaced femoral neck fractures.

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.

Biases in a randomized comparison of three types of screw fixation in displaced femoral neck fractures

We studied fixation of displaced femoral neck fractures prospectively in a randomized multicenter study, comparing 2 Olmed screws, 2 Tronzo screws and 3 Ullevaal hip screws. The study population consisted of 482 women and 125 men, of whom 432 women and 100 men were older than 65 years of age. Their median age was 80 (54-97) years. Despite agreement on criteria, the rates of reoperations for pain and failure--salvage (prosthesis replacement) and other reoperations (removal of implant)--differed significantly between the 3 hospitals regardless of type of fixation. In total, the percentages of salvage operations were: Olmed screw 17/175, Tronzo 17/130 and Ullevaal screw 11/302 (n.s.); the percentages of other reoperations were 11, 6 and 13, respectively (n.s.). In the whole series, the 2-year rate of salvage operations was 14%. No differences between the implants were found in patients older than 65 years of age. We conclude that an agreed, common definition of a hard end-point (reoperation) does not ensure comparability of results, because of differences in clinical decision making.

Choice of implant for internal fixation of femoral neck fractures. Meta-analysis of 25 randomised trials including 4,925 patients

We reviewed all randomised trials comparing different implants for treating intracapsular fractures of the hip and, where possible, the data were combined. 25 randomised trials were identified involving 4,925 patients. Screws appeared to be superior to pins. It was not possible to determine the optimum number or type of screws. No advantage was shown for an implant with a side-plate.

Rigid osteosynthesis decreases the late complication rate after femoral neck fracture. The influence of three different osteosynthesis devices evaluated in 369 patients

The influence of three different fixation devices on late healing complications after femoral neck fractures was studied in a large patient group from three different hospitals. Except for the choice of device, which was unique to each hospital, all other factors having a potential influence on the late outcome, such as sex and age of the patients, initial degree of fracture dislocation and quality of surgical reduction were similar among the three groups. Within a 2-year observation period the incidence of late segmental collapses (14%-19%) was not related to choice of device, but a higher number of non-unions (27%-30%) occurred after adaptive non-rigid methods using screws (von Bahr) or a flanged nail (Rydell) than after a more rigid osteosynthesis (8%, Deyerle). Using such a rigid fixation, the complication rate could be reduced by one-third and the need for revision surgery halved. A device providing stable fixation should be preferred for treatment of femoral neck fractures in the elderly to prevent the healing complications related to insufficient stabilization.

Radiographic prediction of failure after fixation of cervical hip fracture

During 1984-1985, 410 patients with cervical hip fracture were randomized between 2 methods of internal fixation--a single nail (Rydell) or 2 LIH hook pins (LIH). The patients were followed-up prospectively for at least 2 years. Radiographs were taken after 1 week, 1, 3, 6, 12, and 24 months. The radiographs of the 295 patients alive 2 years postoperatively were examined by one of the authors. The sliding and the diversion of the pins and the nail in the anteroposterior projection and the diversion in the lateral projection were measured. In the failure group (non-union, late segmental collapse), the greatest sliding was noted within 1 month postoperatively and the diversion increased up to 3 months. Significant differences between the failure and the non-failure groups could be seen even after 1 week. We also found that the degree of sliding of the LIH pins and the Rydell nail 1 month postoperatively is comparable to the scintigraphic pattern 2 weeks postoperatively in predicting failure after internal fixation of cervical hip fractures.

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.

An algorithm for assessment of fracture displacement and pin positions in femoral neck fractures

A method for determination of both the displacement of the femoral head and the position of the fixation device in fixed femoral neck fractures is described. In routine AP and lateral radiographs of the hip, measurements are made of femoral neck-shaft angle, the diameter of the femoral head and neck, the distances from the center of the femoral head to the femoral neck axis and the distances from the femoral neck axis to the fixating screws. From these values the position of the femoral head and the fixating screws are determined by geometric calculations. A computer program in Q-BASIC was devised to perform the calculations and to produce graphic displays of cross-sections of the femoral head and neck, with the displacement of the head and the screw positions indicated. The accuracy of the method was evaluated by a new method using axial radiographs of hip specimens, which were compared with the computer-plotted graphs of the femoral head and neck. The mean error of the method was found to be +/- 5% of the femoral head diameter, approximately 2.5 mm.

Outcomes after displaced fractures of the femoral neck. A meta-analysis of one hundred and six published reports

Methods of meta-analysis, a technique for the combination of data from multiple sources, were applied to analyze 106 reports of the treatment of displaced fractures of the femoral neck. Two years or less after primary internal fixation of a displaced fracture of the femoral neck, a non-union had developed in 33 per cent of the patients and avascular necrosis, in 16 per cent. The rate of performance of a second operation within two years ranged from 20 to 36 per cent after internal fixation and from 6 to 18 per cent after hemiarthroplasty (relative risk, 2.6; 95 per cent confidence interval, 1.4 to 4.6). Conversion to an arthroplasty was the most common reoperation after internal fixation and accounted for about two-thirds of these procedures. The remaining one-third of the reoperations were for removal of the implant or revision of the internal fixation. For the patients who had had a hemiarthroplasty, the most common reoperations were conversion to a total hip replacement, removal or revision of the prosthesis, and débridement of the wound. Although we observed an increase in the rate of mortality at thirty days after primary hemiarthroplasty compared with that after primary internal fixation, the difference was not significant (p = 0.22) and did not persist beyond three months. The absolute difference in perioperative mortality between the two groups was small. An anterior operative approach for arthroplasty consistently was associated with a lower rate of mortality at two months than was a posterior approach. Some reports showed promising results after total hip replacement for displaced fractures of the femoral neck; however, randomized clinical trials are still needed to establish the value of this treatment.

Cortical screw support in femoral neck fractures. A radiographic analysis of 87 fractures with a new mensuration technique

In 87 femoral neck fractures, operated on with 2 von Bahr screws and followed for up to 2 years, the positions of the fixating screws were determined with a new mensuration technique which compensates for the variations in hip rotation in routine radiographs. The union rate of the fractures was related to the position of the screws. A posterior placement of the proximal screw and an inferior placement of the distal screw in both the femoral head and neck improved the outcome substantially.

Changing methods of hip fracture osteosynthesis in Sweden. An epidemiological enquiry covering 46,900 cases

An enquiry covering all hospitals in Sweden operating on hip fractures was conducted in 1990. The results were compared with enquiries from 1982 and 1985. In cervical hip fractures the use of single nail has almost disappeared in favor of 2 LIH hook pins and, lately, the Uppsala subchondral screws. Primary hip prosthesis is the ultimate method of choice in Sweden. Among trochanteric hip fracture the Ender nail has almost totally been replaced by a sliding screw and plate device.

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.

Internal fixation of femoral neck fractures. Dynamic Hip and Gouffon screws compared in 73 patients

A prospective, randomized study comparing the Dynamic Hip screws and the Gouffon screws in the treatment of femoral neck fractures was terminated before the planned number of patients had been admitted, owing to a preponderance of early failure of the Gouffon screws (P 0.014); thus only 73 patients entered the study. After three years' follow-up, 25/38 Gouffon screws and 12/35 Dynamic Hip screws had failed. Six patients treated with Gouffon screws and 14 treated with Dynamic Hip screws had died. The outcome still favoured the use of Dynamic Hip screws (P 0.02).

The uncemented bipolar hemiarthroplasty for displaced femoral neck fractures. 6-year follow-up of 171 cases

We report a study of 168 consecutive patients (171 prostheses) with a displaced femoral neck fracture and a physiologic age older than 75 years who were treated with an uncemented bipolar Monk hard-top hemiarthroplasty. Four prostheses dislocated postoperatively, but none after discharge. Two prostheses were later extracted. Five patients sustained an ipsilateral femoral fracture. Totally, 7 patients (4 percent) were reoperated on. One year after the operation, 22 percent of the patients were dead. An increased mortality rate was recorded during the first 6 months after surgery. At follow-up 6 (3-9) years after the operation, 4 of the 62 patients alive had weight-bearing pain. Three had subsidence of the prosthesis, but none had protrusion of the acetabulum. Ninety-five percent of the patients were free from complications requiring a reoperation or outpatient evaluation.

Fixation of femoral neck fractures. A four-flanged nail versus threaded pins in 200 cases

Two methods of internal fixation for cervical hip fractures were compared in a "randomized to surgeons" type of study. One hundred patients were treated with the Rydell four-flanged nail and 100 with the Gouffon pins. Redisplacement, nonunion, or segmental collapse occurred in 27 patients operated on with the Rydell nail and in 29 patients operated on with the Gouffon pins. According to the actuarial method of follow-up, the failure rates after 2 years were 31 and 33 percent in the two groups.

Internal fixation of 410 cervical hip fractures. A randomized comparison of a single nail versus two hook-pins

Totally, 410 patients with a cervical hip fracture were randomized between two methods of osteosynthesis: a single nail (Rydell) and two hook-pins (LIH). Seventy-five percent of the patients were women. Sixty-nine percent were alive after 2 years. The patients were followed up with clinical and radiographic examinations for 2 years postoperatively. No difference between the two groups were found regarding quality of reduction, early displacement within 3 months, extraction after healing, nonunion, late segmental collapse, or reoperation with a total hip arthroplasty. Nor did we find any differences between the two groups when selecting those alive after 2 years or when dividing the fractures in displaced and nondisplaced fractures.

Fixation of 220 femoral neck fractures. A prospective comparison of the Rydell nail and the LIH hook pins

220 patients with femoral neck fractures were randomly treated with either a Rydell nail (n 110) or two LIH hook pins (n 110). The age, sex, and displacement patterns were similar in both group. All the patients were operated on by orthopedic specialists and followed clinically and radiographically for 2 years or until death. The mortality at 2 years was similar (28 percent) in both groups. Among 154 survivors, early redisplacement or nonunion was recorded in 19 percent of the Rydell-nailed fractures and 32 percent of the LIH-pinned fractures. In nondisplaced fractures, complications occurred in 8/30 Rydell cases compared with 3/16 in the LIH group. In displaced fractures, complications occurred in 21/48 Rydell cases compared with 28/60 in the LIH group.

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.

Hook-pin fixation of subcapital fractures of the femur: an atraumatic procedure?

Eighty-seven patients with subcapital fractures of the femur treated by hook-pin fixation were reviewed clinically and radiologically with an average follow-up time of 29 months. There were 58 undisplaced and 29 displaced fractures. Seven per cent of the undisplaced and 31 per cent of the displaced fractures developed avascular necrosis (AVN) and failure of fixation was seen in 3.5 per cent and 10 per cent respectively. Overall, 23 per cent of patients developed healing complications of which just over one-half had revision arthroplasty. The AVN rate in the undisplaced group was relatively low, though there was no clear advantage over simple screw fixation. In contrast, the incidence of AVN in displaced fractures was higher than with other methods. Fixation failure was related to surgical error in most instances.

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.

Fixation of femoral neck fractures. Comparison of the Uppsala and von Bahr screws

In a prospective randomized study, a newly developed so-called Uppsala technique for internal fixation of femoral neck fractures was compared with the von Bahr technique. The series consisted of 222 consecutive patients, 167 women and 55 men, with a mean age of 80 years. Half of the patients were randomized to each treatment group. During the first postoperative year, 18 failures occurred in the Uppsala group, compared with 39 in the von Bahr group (P less than 0.01). Of 128 patients without pain at 4 months, 9 developed failures, compared with 29 of the 37 that had pain at this time (P less than 0.001). We conclude that the new technique gives better results during the first postoperative year and that most failures occur among those with pain at 4 months. Follow-up radiography is indicated only in patients with pain at 4 months.

Fixation of femoral neck fracture. Prospective comparison of von Bahr screws, Gouffon screws, and Hessel pins

We report a prospective study of 214 patients with femoral neck fractures operated on with multiple pinning. The fractures were randomly allocated to fixation with either von Bahr screws or Hessel pins in 1983 and 1984 or von Bahr or Gouffon screws in 1984 and 1985. After 2 years, the failure rate was one third in the von Bahr and the Gouffon screw groups and one half in the Hessel pin group. We conclude that the nonthreaded Hessel pin is inferior to the von Bahr and Gouffon screws for fixation of femoral neck fractures.

Hemarthrosis after femoral neck fracture fixation

In 34 femoral neck fractures, CT was performed within 1-32 days after internal fixation. All the cases except one showed an increased distance between the femoral neck and the anterior aspect of the joint capsule as compared with the intact side, indicating varying degrees of hip joint effusion and/or synovitis. Hip joint aspiration in 11 patients revealed increased intracapsular pressure varying between 10 and 112 mmHg and volumes of aspirated joint effusion up to 23 ml. Pain relief and increased joint motion after drainage of the intracapsular effusion was observed in 3 patients whose postoperative mobilization was facilitated.

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.

Internal fixation of femoral neck fracture. No difference between the Rydell four-flanged nail and Gouffon's pins

Two methods of internal fixation of femoral neck fractures were compared in a prospective randomized study of 223 patients. Radiographic evidence of early redisplacement, nonunion, or late segmental collapse occurred in 45 of 122 patients operated on with the Rydell four-flanged hook nail and in 33 of 101 patients operated on with Gouffon pins. According to the actuarial method of follow-up, the failure rates after 2 years were respectively 41 and 35 percent in the nail and pin groups, which is a nonsignificant difference.

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.

Sequential scintimetry after femoral neck fracture. Methodologic aspects and prediction of healing complications

Forty-five patients with recent cervical hip fractures were included in a prospective, clinical, radiographic and sequential scintimetric study. Striking changes in radionuclide uptake over the entire hip region on the fracture side were found during the first 5 postoperative months. Fractures that healed without complications showed the highest relative femoral head uptake at 1 week and a peak value at 6 weeks, followed by a gradual decline at the subsequent examinations. Fractures with complications (redisplacement, nonunion, or late segmental collapse) showed a lower initial uptake and a more gradual increase and only a slight tendency towards increased uptake after 3 months. The accuracy in predicting nonunion with scintimetric examination alone is high both at 1 and at 6 weeks, and the accuracy is almost equally high with combined scintimetric, radiographic, and clinical assessment 3-5 months postoperatively.

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.

Correlation of 99mTc-MDP scintimetry and histology in cervical hip fracture

In 20 cases of fresh cervical hip fracture, treated with primary prosthetic replacement, preoperative 99mTc-MDP scintimetry was compared with histologic findings of the extracted femoral heads. The radionuclide uptake was classified into three types according to the activity distribution; overall increase, focal decrease, and overall decrease. Histologically, the location and extent of ischemic necrosis in the femoral heads were closely related to the distribution of decreased activity.

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.