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

Advances in the treatment of intracapsular hip fractures in the elderly

A review of recent advances in the treatment of intracapsular hip fractures in the elderly patient is offered to provide some guidelines on choosing the appropriate treatment for a given patient. Alternatives discussed include open reduction and internal fixation versus arthroplasty; unipolar versus bipolar hemiarthroplasty versus total hip arthroplasty; cemented versus cementlless prostheses; and a surgical approach. These recommendations are based upon a review of the substantial literature on the subject and the author's own experience. It is recommended that patients more than 60-years-old with a femoral neck fracture be treated in the following manner: Patients with undisplaced, stable fractures perform an ORIF, patients with displaced fractures, replace the head of the femur, the use of a Moore or Thompson prostheses should be relegated to the medically infirm, minimally ambulatory patient, modular unipolar or bipolar (cemented stem) hemiarthroplasty has the most reliable and predictable outcome in most patients, an uncemented modular hemiarthroplasty should be considered in patients with significant cardiovascular risk factors, THA perhaps recommended for the "active elderly patient". The use of large heads and meticulous capsular repair techniques will reduce the early dislocation rate while still allowing excellent long-term functional outcomes.

A randomised study in all cervical hip fractures osteosynthesis with Hansson hook-pins versus AO-screws in 199 consecutive patients followed for two years

A consecutive series of patients with all types of cervical hip fracture (both undisplaced and displaced) were randomised to osteosynthesis with Hansson hook-pins (n = 98) or AO-screws (n = 101). Background parameters, fracture type and reduction of the fracture did not differ significantly between the groups. Fifty-seven percent of the patients were operated on within 6 h of admission to hospital, 74% within 12 h and 92% within 24 h. The mean (median) time for operation was 36 (30) min for the hook-pins and 40 (35) min for the AO-screws. The devices were significantly better positioned in the hook-pin group (81% of cases good) compared to the AO-screws (66% good) (p = 0.04). In all, 72% of the patients had no deficiency either in reduction of the fracture, positioning of the implants or had drill penetration of the femoral head. Direct unrestricted weight bearing was encouraged in 92% of the hook-pin and 90% of the AO-screws group. The mean (median) hospital time was 13 (10) days with no significant difference between the groups. Following treatment, 5% walked without aids, 76% of the patients walked with some aids, and 16% could not walk. The walking ability was not known for 4%. At four months, 59% of the patients were living in their own home (64% before fracture), 18% (25% before) in a nursing home, 5% (11% before) in other accommodation and 18% were dead. After two years, 77% of the hook-pin patients had not needed any re-operation compared to 73% in the AO-screw group. In total a secondary hemi-arthroplasty had been performed in 7% and total hip arthroplasty in 12% of the patients. Extraction only of osteosynthesis material had been performed in 5%. The difference in the reoperation rates between the two methods was not significant. In the undisplaced fractures, 84% of the patients had not needed any reoperation after two years compared to 70% among the displaced fractures. Major reoperation had been performed in 10% (1% hemi and 9% total hip arthroplasty) in the patients with undisplaced fractures compared to 26% in those with displaced fractures (10% hemi, 16% total hip arthroplasty and 1% Girdlestone operation). The remaining patients had only undergone removal of metalwork. Osteosynthesis thus proved to be a successful operation in many of the patients with displaced fractures. A preoperative, prognostic-based selection between osteosynthesis and arthroplasty is the future goal for optimised femoral neck fracture treatment.

Femoral neck fractures in the elderly: functional outcome and quality of life according to EuroQol

The main purpose of this prospective study was to investigate the functional outcome and health-related quality of life according to EuroQol (EQ-5D) after a femoral neck fracture treated with internal fixation in relatively healthy elderly patients. We also aimed to validate the use of the EQ-5D in routine clinical follow-ups of this group of patients. The inclusion criteria were more than 65 years of age, absence of severe cognitive dysfunction, living independently, and unhindered walking ability preoperatively. The mean follow-up period was 17 months. The rated prefracture EQ-5Dindex scores showed good correspondence with the scores of an age-matched Swedish reference population. The EQ-5Dindex scores decreased from 0.78 before the fracture (based on recall) to 0.59 at 4 months and 0.51 at 17 months after surgery. The decrease was significantly larger among patients with fracture healing complications. There was a good correlation between the EQ-5Dindex scores and other outcome measures such as pain, mobility, independence in ADL and independent living status. The questionnaire response rate (EQ-5D) was 89-100% on different follow-up occasions. The EQ-5D appears to be an easy-to use instrument even for elderly patients with femoral neck fractures. Changes in the quality of life may be useful to identify patients who might benefit from reoperation, i.e. arthroplasty. The EQ-5D also appears to be a relevant clinical end-point in outcome studies.

Quality of life related to fracture displacement among elderly patients with femoral neck fractures treated with internal fixation

OBJECTIVE

To determine differences in outcome between undisplaced (Garden I and II) and displaced (Garden III and IV) femoral neck fractures in elderly patients treated with internal fixation.

SETTING

University hospital.

DESIGN

Prospective clinical study.

PATIENTS

Ninety patients with an acute femoral neck fracture after a fall. The inclusion criteria were age older than sixty-five years, absence of severe cognitive dysfunction, independent living, and unhindered walking capability preoperatively. The mean follow-up was twenty-six months.

INTERVENTION

The patients were treated with closed reduction and percutaneous internal fixation with two cannulated screws.

MAIN OUTCOME MEASUREMENTS

Fracture healing complications, pain (visual analogue scale), walking capability, activities of daily living, and quality of life according to EuroQol.

RESULTS

The rate of fracture healing complications in displaced femoral neck fractures in patients available at the final follow-up was 36 percent compared with 7 percent in patients with undisplaced fractures. The quality of life, according to EuroQol, of patients with uneventfully healed fractures was significantly lower in patients with primarily displaced fractures (0.51) than in patients with undisplaced ones (0.76).

CONCLUSION

There was a major difference in outcome on comparing undisplaced and displaced femoral neck fractures in elderly patients treated with internal fixation. The rate of fracture healing complications in patients with undisplaced fractures was low, and patients with healed fractures regained their prefracture quality of life level. The rate of fracture healing complications and reoperations in patients with displaced fractures was high, and even in patients with uneventfully healed fractures, there was a substantial decrease in the quality of life.

Results of conversion total hip prosthesis performed following painful hemiarthroplasty

Fifteen of 18 cases who underwent conversion total hip prosthesis due to painful hemiarthroplasty, between 1992 and 1997, were investigated retrospectively. The 13 (86.6%) women and two (13.4%) men (mean age, 59 years) were followed up for an average of 32 months. Pre-operative and post-operative Harris hip scores were 36.4 (28 - 42) and 85.9 (69 - 98), respectively. In all cases the femoral component had more than 2 mm radiolucency in Gruen zones I, IV and VII, and five cases had acetabular protrusion; other cases had cartilage erosion. In the last follow-up of conversion total hip prosthesis, there was no radiolucency in either femoral or acetabular components. Comparing our results of conversion total hip prosthesis with primary total hip prosthesis results for femoral neck fractures in the literature we conclude that, in elderly patients with femoral neck fractures, primary total hip prosthesis has better results.

Non-operative or operative treatment for undisplaced femoral neck fractures: a comparative study of 122 non-operative and 125 operatively treated cases

We present a series of 247 undisplaced femoral neck fractures, of which 122 were primarily treated non-operatively, and 125 with primary operative stabilization. The background parameters did not differ significantly in the two groups. The length of hospitalization was 1 week shorter in the operatively treated group. They started to walk bearing full weight at an average of 11 days earlier. Two-thirds of the operatively treated but only one-quarter of the non-operatively treated patients were able to walk alone when they left hospital. General complications were recorded in 19 of the non-operatively and in four of the operatively treated patients during their hospitalization. Early displacement (within 6 weeks) was noted in 20 per cent of the non-operatively treated patients who required late operation. However, there was no early displacement in the operatively treated group. We therefore recommend primary operative stabilization of undisplaced femoral neck fractures.

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.

Treatment and survival among elderly Americans with hip fractures: a population-based study

OBJECTIVES

This study was undertaken to examine the patterns of treatment and survival among elderly Americans with hip fracture.

METHODS

A 5% national sample of Medicare claims was used to identify patients who sustained hip fractures between 1986 and 1989. In comparing treatment patterns across regions, direct standardization was used to derive age- and race-adjusted percentages. Logistic regression and Cox regression were used to examine short- and long-term survival.

RESULTS

In the United States, 64% of femoral neck fractures were treated with arthroplasty; 90% of pertrochanteric fractures were treated with internal fixation. Higher short- and long-term mortality was associated with being male, being older, residing in a nursing home prior to fracture, having a higher comorbidity score, and having a pertrochanteric fracture. Blacks and Whites had similar 90-day postfracture mortality, but Blacks had a higher mortality later on. For femoral neck fracture, internal fixation has a modestly lower short-term mortality associated with it than arthroplasty has.

CONCLUSION

Variation in the treatment of hip fracture was modest, The increased delayed mortality after hip fracture among Blacks requires further study.

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.

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.

Quality of life after primary hemiarthroplasty for femoral neck fracture. 6-year follow-up of 185 patients

Totally, 185 patients with a mean age of 80 years treated by Austin-Moore cementless hemiarthroplasty for an acute femoral neck fracture were compared with age- and sex-matched nonfracture controls. There were 22 early complications, notably 7 percent dislocation and 4 percent deep infection. Later on, two acetabular protrusions and four loosenings of the prosthesis requiring admission were recorded. Mortality after the fracture was 12 percent above the control level at 3 months, 19 percent at 12 months, and 21 percent at 18 months. The 5-year mortality was about 60 percent in both patients and controls. The average loss of life in the fracture group compared with the control group was 425 days. After a mean follow-up period of 6 years, 24 of the 65 patients still alive and the 49 of the 60 controls were living in their own homes; and 28 of the patients were institutionalized in a hospital unit for chronic care. Half of the patients and most of the controls were able to move about independently. We concluded that Austin-Moore hemiarthroplasty is associated with serious complications that prevent social rehabilitation and function to reach acceptable levels.

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.

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.