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

Valgus-impacted subcapital neck of femur fractures: a systematic review, meta-analysis with cost analysis of fixation in-situ versus nonoperative management

BACKGROUND

The management of the valgus-impacted neck of femur fracture (AO/OTA 31-B1) remains contentious. The objective of this study was to determine whether operative intervention is cost-effective.

METHODS

We conducted a systematic review using electronic databases (Medline, Embase, Cochrane, Ebsco, Scholar) identifying studies published in the English language concerning valgus-impacted neck of femur fractures until June 2022. Additional studies were identified through hand searches of major orthopaedic journals, and bibliographies of major orthopaedic textbooks. MeSH terms (hip fracture and femoral neck fracture) and keywords (undisplaced, valgus-impacted, valgus, subcapital, Garden) connected by the Boolean operators "AND" and "OR" were used to identify studies. 2 reviewers independently extracted the data using standardised forms and recording spreadsheet. Methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-analysis of Statistics Assessment and Review Instrument. Meta-analysis was undertaken. Outcome measures were rate of displacement, avascular necrosis, non-union, mortality and requirement of further operative intervention. A cost utility analysis was then conducted to compare the 2 groups on the basis of the cost of initial treatment and the potential requirement of secondary intervention to hemiarthroplasty.

RESULTS

47 studies met the inclusion criteria. Meta-analysis data demonstrated a significant difference in the displacement rate of 22.8% and 2.8% between the nonoperative and internal fixation groups respectively (p = 0.05). The overall incidence of further operative intervention for each group was 23% and 10% respectively. There was no significant difference with respect to avascular necrosis, mortality or union rates. The cost utility analysis revealed nonoperative management to be approximately 60% more costly than initial internal fixation when the costs of subsequent surgery were included.

CONCLUSIONS

This meta-analysis of the existing literature concludes that whilst nonoperative management is possible for valgus impacted neck of femur fractures, it is associated with higher complication rates and greater expense than management by internal fixation.

Comparative Study for Osteosynthesis of Femoral Neck Fractures: Cannulated Screws versus Femoral Neck System

Purpose

The purpose of this study is to compare the radiological results of fixation using the femoral neck system (FNS) and cannulated screw (CS) for treatment of femoral neck fractures.

Materials and Methods

A retrospective study of patients with femoral neck fractures who underwent internal fixation and had follow-up of more than six months from 2010 to 2020 was conducted. A total of 87 patients were enrolled in the study. The FNS group included 20 patients and the CS group included 67 patients. Classification of fractures was performed according to Garden and Pauwels classification. Operation time, intraoperative blood loss, sliding distance of the implant, lateral soft tissue irritation caused by implants, and complications were evaluated.

Results

The mean operation time was 40.30 minutes in the FNS group and 46.84 minutes in the CS group. The mean intraoperative bleeding volume was 51.25 mL in the FNS group and 72.16 mL in the CS group. Bone union was achieved in 18 patients in the FNS group (90.0%) and in 61 patients in the CS group (91.0%). The mean sliding distance of the implant was 4.06 mm in the FNS group and 3.92 mm in the CS group. No patients in the FNS group and 12 patients in the CS group complained of soft tissue irritation.

Conclusion

A shorter operative time, less intraoperative bleeding, and less irritation of soft tissue were observed in the FNS group. FNS could be an alternative to CS for fixation of femoral neck fractures.

Higher stability and more predictive fixation with the Femoral Neck System versus Hansson Pins in femoral neck fractures Pauwels II

Objectives

To evaluate the biomechanical performance of the Femoral Neck System (FNS) versus the Hansson Pin System (Hansson Pins) with two parallel pins in a Pauwels II femoral neck fracture model with posterior comminution.

Methods

Forty-degree Pauwels II femoral neck fractures AO 31-B2.1 with 15° posterior wedge were simulated in fourteen paired fresh-frozen human femora, followed by instrumentation with either FNS or Hansson Pins in pair-matched fashion. Implant positioning was quantified by measuring shortest implant distances to inferior cortex (DI) and posterior cortex (DP) on anteroposterior and axial X-rays, respectively. Biomechanical testing was performed in 20° adduction and 10° flexion with simulated iliopsoas muscle tension. Progressively increasing cyclic loading was applied until construct failure. Interfragmentary femoral head-to-shaft movements were measured with optical motion tracking.

Results

Cycles to 10° varus deformation were significantly higher for FNS (23007 ​± ​5496) versus Hansson Pins (17289 ​± ​4686), P ​= ​0.027. Cycles to 10° femoral head dorsal tilting (FNS: 12765 ​± ​3425; Hansson Pins: 13357 ​± ​6104) and cycles to 10° rotation around the femoral neck axis (FNS: 24453 ​± ​5073; Hansson Pins: 20185 ​± ​11065) were comparable between the implants, P ​≥ ​0.314. For Hansson Pins, the outcomes for varus deformation and dorsal tilting correlated significantly with DI and DP, respectively (P ​≤ ​0.047), whereas these correlations were not significant for FNS (P ​≥ ​0.310).

Conclusions

From a biomechanical perspective, by providing superior resistance against varus deformation and performing in a less sensitive way to variations in implant placement, the angular stable Femoral Neck System can be considered as a valid alternative to the Hansson Pin System for the treatment of Pauwels II femoral neck fractures.

Level of evidence

therapeutic, Level V.

The Translational potential of this article

The translational potential of this article is to compare the performance of the FNS with Hansson Pins in a AO 31-B2.1 fracture model featuring a 15 posterior wedge to show the implants behavior concerning the dorsal tilting tendency.

Risk of reoperation within 12 months following osteosynthesis of a displaced femoral neck fracture is linked mainly to initial fracture displacement while risk of death may be linked to bone quality: a cohort study from Danish Fracture Database

Background and purpose - Most guidelines use patient age as a primary decision factor when choosing between osteosynthesis or arthroplasty in displaced femoral neck fractures. We evaluate reoperation and death risk within 1 year after osteosynthesis, and estimate the influence of age, sex, degree of displacement, and bone quality.Patients and methods - All surgeries for femoral neck fractures with parallel implants (2 or 3 screws or pins) performed between December 2011 and November 2015 were collected from the Danish Fracture Database. Radiographs were analyzed for initial displacement, quality of reduction, protrusion, and angulation of implants. The bone quality was estimated using the cortical thickness index (CTI). Garden I and II type fractures with posterior tilt < 20° were excluded.Results - 654 patients with a mean age of 69 years were included. 59% were female. 54% were Garden II with posterior tilt > 20° or Garden III, and 46% were Garden IV. Only 38% were adequately reduced. 19% underwent reoperation and 18% died within 12 months. Female sex, surgical delay between 12 and 24 hours vs. < 12 hours, Garden IV type fracture, inadequate reduction, and protrusion of an implant were associated with statistically significant increased reoperation risk. No significant association between reoperation and age, CTI, or the initial angulation of implants was found. Notably, CTI was linked inversely with death risk.Interpretation - Reoperation risk is linked mainly to primary displacement and reduction of the fracture, with no apparent effect of age or bone quality. Bone quality may be linked with risk of death.

Screw Fixation Versus Hemiarthroplasty for Nondisplaced Femoral Neck Fractures in Elderly Patients: A Multicenter Randomized Controlled Trial

BACKGROUND

Elderly patients with a displaced femoral neck fracture treated with hip arthroplasty may have better function than those treated with internal fixation. We hypothesized that hemiarthroplasty would be superior to screw fixation with regard to hip function, mobility, pain, quality of life, and the risk of a reoperation in elderly patients with a nondisplaced femoral neck fracture.

METHODS

In a multicenter randomized controlled trial (RCT), Norwegian patients ≥70 years of age with a nondisplaced (valgus impacted or truly nondisplaced) femoral neck fracture were allocated to screw fixation or hemiarthroplasty. Assessors blinded to the type of treatment evaluated hip function with the Harris hip score (HHS) as the primary outcome as well as on the basis of mobility assessed with the timed "Up & Go" (TUG) test, pain as assessed on a numerical rating scale, and quality of life as assessed with the EuroQol-5 Dimension-3 Level (EQ-5D) at 3, 12, and 24 months postsurgery. Results, including reoperations, were assessed with intention-to-treat analysis.

RESULTS

Between February 6, 2012, and February 6, 2015, 111 patients were allocated to screw fixation and 108, to hemiarthroplasty. At the time of follow-up, there was no significant difference in hip function between the screw fixation and hemiarthroplasty groups, with a 24-month HHS (and standard deviation) of 74 ± 19 and 76 ± 17, respectively, and an adjusted mean difference of -2 (95% confidence interval [CI] = -6 to 3; p = 0.499). Patients allocated to hemiarthroplasty were more mobile than those allocated to screw fixation (24-month TUG = 16.6 ± 9.5 versus 20.4 ± 12.8 seconds; adjusted mean difference = 6.2 seconds [95% CI = 1.9 to 10.5 seconds]; p = 0.004). Furthermore, screw fixation was a risk factor for a major reoperation, which was performed in 20% (22) of 110 patients who underwent screw fixation versus 5% (5) of 108 who underwent hemiarthroplasty (relative risk reduction [RRR] = 3.3 [95% CI = 0.7 to 10.0]; number needed to harm [NNH] = 6.5; p = 0.002). The 24-month mortality rate was 36% (40 of 111) for patients allocated to internal fixation and 26% (28 of 108) for those allocated to hemiarthroplasty (RRR = 0.4 [95% CI = -0.1 to 1.1]; p = 0.11). Two patients were lost to follow-up.

CONCLUSIONS

In this multicenter RCT, hemiarthroplasty was not found to be superior to screw fixation in reestablishing hip function as measured by the HHS (the primary outcome). However, hemiarthroplasty led to improved mobility and fewer major reoperations. The findings suggest that certain elderly patients with a nondisplaced femoral neck fracture may benefit from being treated with a latest-generation hemiarthroplasty rather than screw fixation.

LEVEL OF EVIDENCE

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

Hip Fracture Treatment in Oulu — One-Year Survey with Four-Month Follow-Up

Backgrounds and Aims:

The standardized forms of the Standardized Audit of Hip Fractures in Europe (SAHFE) are aimed for the evaluation of hip fracture treatment in different hospitals and countries. The purpose was to evaluate and characterize a cohort of hip fracture patients with these forms and to evaluate their value in quality control.

Material and Methods:

The non-pathological hip fractures in patients over 49 years of age treated in the Oulu University Hospital were prospectively recorded during a one-year period using SAHFE forms.

Results:

There were 238 (52 male and 186 female) patients with a mean age of 78 (50–102) years. Fifty-nine percent of the patients were admitted from their own homes. Fifty-seven percent were able to walk alone outdoors and 48% could walk without walking aids before the fracture. A hundred and fifty patients had cervical fractures and 88 trochanteric fractures. The most frequent treatment of cervical fractures was Austin-Moore hemiarthroplasty (68%) and that of trochanteric fractures Gamma nail fixation (86%). At four months after the fracture, 50% lived in their own homes, 33% could walk alone out-doors and 13% could walk without any aids. Thirty-two percent had no pain in the hip. The overall mortality at four months was 17.6% and that of the operated patients 16.2%. The reoperation rate was 8.5%.

Conclusion:

SAHFE forms were very useful in the evaluation of the quality of the hip fracture treatment.

Revision surgery occurs frequently after percutaneous fixation of stable femoral neck fractures in elderly patients

BACKGROUND

Femoral neck fractures are a major public health problem. Multiple-screw fixation is the most commonly used surgical technique for the treatment of stable femoral neck fractures.

QUESTIONS/PURPOSES

We determined (1) the proportion of hips that had conversion surgery to THA, and (2) the proportion of hips that underwent repeat fracture surgery after percutaneous screw fixation of stable (Garden Stages I and II) femoral neck fractures in patients older than 65 years and the causes of these reoperations.

METHODS

We performed a retrospective study of all patients older than 65 years with stable femoral neck fractures secondary to low-energy trauma treated surgically at our institution between 2005 and 2008. We identified 121 fractures in 120 patients older than 65 years as stable (Garden Stage I or II); all were treated with percutaneous, cannulated screw fixation in an inverted triangle without performing a capsulotomy or aspiration of the fracture hematoma at the time of surgery. The average age of the patients at the time of fracture was 80 years (range, 65-100 years). Radiographs, operative reports, and medical records were reviewed. Fracture union, nonunion, osteonecrosis, intraarticular hardware, loss of fixation, and conversion to arthroplasty were noted. Followup averaged 11 months (range, 0-5 years) because all patients were included, including those who died. The mortality rate was 40% for all patients at the time of review.

RESULTS

Twelve patients (10%) underwent conversion surgery to THA at a mean of 9 months after the index fracture repair (range, 2-24 months); the indications for conversion to THA included osteonecrosis, nonunion, and loss of fixation. Two others had periimplant subtrochanteric femur fractures treated by surgical repair with cephalomedullary nails and two patients had removal of hardware.

CONCLUSIONS

Revision surgery after osteosynthesis for stable femoral neck fractures was more frequent in this series than previously has been reported. The reasons for this higher frequency of reoperation may be related to poor bone quality, patient age, and some technical factors, which leads us to believe other treatment options such as nonoperative management or hemiarthroplasty may be viable options for some of these patients.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

[Percutaneous screw osteosynthesis of femoral neck fractures in the elderly. Subtrochanteric fractures as severe complications]

Percutaneous osteosynthesis by cannulated screws is a well established method for the treatment of non-displaced femoral neck fractures, especially in elderly patients with comorbidities due to low operative invasiveness. Optimal screw placement is still under discussion. There are only few literature references concerning the complication of subtrochanteric femoral fractures. We performed a review of the literature and a retrospective analysis of our patients treated by this form of osteosythesis from 01.04.2004 to 30.09.2009 searching for screw placement and the incidence of subtrochanteric femoral fractures. This complication was found in 2 of our 35 patients (5.7%) without adequate trauma, such as a stumble or fall having occurred.

Influence of age, sex, fracture type and pre-fracture living on rehabilitation pattern after hip fracture in the elderly

PURPOSE

To evaluate the influence of background factors on the rehabilitation pattern after a hip fracture in the elderly.

METHOD

Prospective registration based on the Swedish national register for hip fracture patients called RIKSHOFT/SAHFE (Standardised Audit of Hip Fractures in Europe). The place of living was registered both before fracture and during the following four months period (120 days). Graphs were calculated and drawn based on day-to-day changes. Also influences of age, sex, fracture type and type of operation were analyzed.

RESULTS

The patient's pre-fracture functional capacity as evidence by the place they were able to manage to live before the fracture was the most discriminating factor for the rehabilitation; more than sex, fracture type or type of operation. Age was also a highly discriminating factor with a pronounced influence on the rehabilitation pattern.

CONCLUSIONS

These background parameters are very important factors when planning the rehabilitation of hip fracture patients. A strategy with individualized planning of the rehabilitation procedure will be highly necessary in the future, in view of the increasing amount of elderly with hip fractures prognosticated during the coming decades. The knowledge about influencing factors here presented will be useful when planning and performing the rehabilitation for this resource-consuming group of patients.

Undisplaced femoral neck fractures--no problems? A consecutive study of 224 patients treated with internal fixation

224 patients with undisplaced femoral neck fractures treated with two parallel Hansson hook pins were studied. After a mean follow-up time of 32 months (S.D. 5.2), 15% had a reoperation. 11% were considered failures, mostly avascular necrosis, and 9% had a secondary arthroplasty. Possible risk factors for poor outcome were analysed. Neither high age nor surgical delay was associated with increased failure rate. Survivors received a questionnaire, and 40% stated that they had mild or severe pain in the hip when walking, 25% had pain at rest and 25 stated that they thought "always" or "often" about their injury. The younger the patient, the more frequent the report of subjective pain. 51% of individuals under 80 years reported pain when walking, compared to 27% aged 80 or older (p=0.016). Corresponding numbers for pain at rest were 32 and 12% (p=0.034). The failure rate did not differ between the age groups, but the younger patients had more reoperations (p=0.046) and thought more frequently about their injury (p=0.016). An undisplaced femoral neck fracture is a major injury with a long-term daily discomfort in about 25% and clinical failure in 11%.

Influence of optimised treatment of people with hip fracture on time to operation, length of hospital stay, reoperations and mortality within 1 year

Hip fractures are a major cause of hospital stay among the elderly, and result in increased disability and mortality. In this study from 1 April 2003 to 31 March 2004, the influence of optimised treatment of hip fracture on time to operation, length of hospital stay, reoperations and mortality within 1 year were investigated. Comparisons were made between the first 210 patients in the period and the last 210 patients, who followed the new clinical pathway introduced at the University Hospital in Lund, Sweden. Early surgery, within 24h, was not associated with reduced mortality, but was significantly associated with reduced length of stay (p<0.001). Significantly more cases of osteosynthesis for femoral neck fracture were reoperated compared with all other types of surgery (p<0.001) when reoperations with extraction of the hook pins in healed fractures were excluded. Mortality was significantly higher among men than women at 4 (p=0.025) and 12 (p=0.001) months after fracture and among medically fit patients with administrative delay to surgery compared with patients with no delay (p<0.001).

Twin hook fixation for proximal femoral fractures

PURPOSE

To report results of twin hook fixation for proximal femoral fractures in comparison to those fixed with the conventional lag screw.

METHODS

Between August 2005 and July 2006, 2 men and 15 women aged 74 to 94 (mean, 85) years with proximal femoral fractures underwent open reduction and internal fixation using the twin hook system. The tip-apex distance was compared with that in 20 patients treated with the sliding hip screw between August 2004 and July 2005.

RESULTS

In the 17 patients, the hook was inserted into the centre of the femoral head. Bone union was achieved and no intra- or post-operative cut-out or device failure was encountered. In patients using the twin hook and sliding hip screw respectively, the mean tip-apex distance was 22.3 mm and 14.6 mm (p<0.001).

CONCLUSION

Using the twin hook system requires more surgical skill than using the sliding hip screw, because failure to insert the pin into the centre of the femoral head risks intra-articular perforation by the hooks.

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.

Evaluation of the learning curves associated with uncemented primary total hip arthroplasty depending on the experience of the surgeon

The aim of the paper is to prove and to portray the learning curve in total hip arthroplasty. This prospective study included 168 patients who were operated on by three surgeons, all demonstrating different degrees of experience in performing total hip arthroplasty. Perioperative complications and postoperative radiographs were analysed. Patients were re-examined clinically and radiologically five years postoperatively. In addition, a second study with 41 patients was performed, evaluating especially the learning curve of the highly skilled surgeon in using a femoral neck prosthesis. Radiological complications presented by the first 84 operated patients (2 nd study: 25 hips) were significantly higher than those in the following 84 patients (2 nd study: 26 hips). The learning curve of all surgeons was completed after 20 operations regardless of their experience. Clinical results at follow-up were not influenced by the learning curve. Intensive preoperative planning and exchange of experiences will reduce the length of the learning curve within and outside every clinic.

Hemiarthroplasty in worst cases is better than internal fixation in best cases of displaced femoral neck fractures: a prospective study of 683 patients treated with hemiarthroplasty or internal fixation

BACKGROUND

Studies have shown that the degree of initial displacement and also comminution of the femoral calcar, size of the head and varus angulation are prognostic of failure in displaced femoral neck fracture. We have applied these radiographic criteria in order to select patients who would benefit from internal fixation as opposed to primary hemiarthroplasty, and this prospective study was conducted in order to monitor the results of this strategy.

METHODS

683 displaced fractures of the femoral neck were treated with internal fixation or primary hemiarthroplasty based on the proposed radiographic criteria in a prospective consecutive study, and the patients were followed for 1-6 years. We treated 228 fractures with internal fixation and 455 by bipolar hemiprosthesis. The choice of operation was based on clinical evaluation of the patient and assessment of the assumed healing potential of the fracture, as determined by radiographic evaluation. Revision and mortality were primary endpoints.

RESULTS

54 (24%) of the patients originally treated by osteosynthesis were revised, whereas 9 (2%) of the patients treated with hemiarthroplasty had revision surgery. There were no significant differences in mortality between the groups at 30, 120 or 365 days.

INTERPRETATION

Even when treating only the fractures with the assumed best healing potential with internal fixation, the results are inferior to hemiarthroplasty.

Responsiveness of the EuroQol (EQ 5-D) and the SF-36 in elderly patients with displaced femoral neck fractures

OBJECTIVES

To evaluate the responsiveness of the EuroQol (EQ-5D) and Short-Form 36 (SF-36) instruments, i.e. their ability to capture clinically important changes, in elderly patients with a displaced femoral neck fracture. The study was part of a prospective randomised study comparing two different surgical procedures, internal fixation (IF) and total hip replacement (THP).

SETTING

University hospital.

PATIENTS

A total of 110 patients, mean age 80 years with an acute displaced femoral neck fracture (Garden III and IV). The inclusion criteria were age > or = 70, absence of severe cognitive dysfunction, independent living status and independent walking capability.

INTERVENTION

The patients were randomised to IF or to a THR.

MAIN OUTCOME MEASUREMENTS

Health-related quality of life according to EQ-5D and SF-36. Responsiveness measured by the ability of the EQ-5D and the SF-36 to detect clinically relevant differences in the study population according to an external criterion (EC) for outcome (good or less good clinical outcome). Responsiveness was measured in terms of change scores, standardised effect size (SES) and standardised response mean (SRM).

RESULTS

The rated prefracture EQ-5D(index) scores and SF-36 scores showed good correspondence with the scores of age-matched Swedish reference populations. The relationship between the EC and EQ-5D(index) score and the SF-36 global score showed significant differences in both comparisons (p < 0.001). The responsiveness expressed with the SES and SRM were large for both the EQ-5D (1.37 and 0.90, respectively) and for the SF-36 global score (0.89 and 0.82, respectively). The correlation between the change scores for the SF-36 global score and the EQ-5D was 0.39 (p < 0.001).

CONCLUSION

The results showed high responsiveness for both the EQ-5D and the SF-36, indicating that both instruments are suitable for use as outcome measures in clinical trials in elderly hip fracture patients.

Early discharge of hip fracture patients from hospital: transfer of costs from hospital to nursing home

Hip fracture patients occupy more and more hospital beds. One of the strategies for coping with this problem is early discharge from the hospital to institutions with rehabilitation facilities. We studied whether early discharge affects outcome and costs. 208 elderly patients with a hip fracture were followed up to 4 months after the fracture. First, a group of 102 patients stayed in our hospital for the usual period (median 18 days). Then, 106 patients were assigned to a group for early discharge (median 11 days). We measured disabilities, health-related quality of life and cognition at 1 week, 1, and 4 months after hospitalization. To calculate total societal costs, inpatient days, the efforts of professionals in- and outside institutions, and interventions/examinations were recorded during this 4-month period. At 4 months, we found no differences in mortality, ADL level, complications, quality of life, and type of residence. More patients in the early discharge group were discharged to nursing homes with rehabilitation facilities (76% versus 53%), but the median total stay in hospital and nursing home was the same (26 days). Early discharge from hospital did not substantially reduce the total costs (conventional management Euro 15,338 per patient and early discharge Euro 14,281 per patient), but merely shifted them from the hospital to the nursing home.

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.

Reduction and fixation of displaced intracapsular fractures of the proximal femur

Intracapsular fractures of the femoral neck are one of the most common fractures in the elderly. The incidence of these fractures will increase significantly in the next decades as a result of increasing life expectancy. Although treatment of these fractures by closed or open reduction and internal fixation is standard in young patients, arthroplasty is the standard treatment in geriatric patients in most countries. Comorbidities of the patients and current socioeconomic changes in healthcare led to reconsideration of closed reduction and internal fixation of femoral neck fractures as an alternative treatment modality. With correct decision-making, proper reduction, and proper consideration of the biomechanical principle of three-point fixation, minimally invasive screw fixation of femoral neck fractures is a safe and inexpensive procedure even in elderly patients. The purpose of the current review was to give an overview of the history, current techniques and developments, results, limitations, and complications of closed reduction and internal fixation of intracapsular femoral neck fractures.

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.

An algorithm for preoperative prediction of reoperation risk after internal fixation of femoral neck fractures

An algorithm was designed for preoperative prediction of the risk for reoperation, and the mortality risk, after internal fixation of femoral neck fractures. Out of 51 reviewed studies of femoral neck fractures, eight met specified inclusion criteria such as low dropout rates, a minimum of ten surgeons performing the surgery, a minimum of 2 years follow-up, and a standard age, sex, and Garden class distribution. Five of these studies were used for the construction of the algorithm, and the remaining three for testing the specificity and sensitivity of the algorithm. A separate analysis of the influence of age on the reoperation rate was also performed. In the analysis of 399 reviewed cases of femoral neck fractures, the specificity for the algorithm in predicting the risk for reoperation was 96%, and the sensitivity was 51%. The positive predictive value for the algorithm in predicting the risk for reoperation was 77%, which was three times higher compared to the commonly used predictors age and Garden class (positive predictive value 25%). For prediction of the mortality risk the positive predictive value for-the algorithm was 57%.

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.

Cannulated screws for fixation of femoral neck fractures. No difference between Uppsala screws and Richards screws in a randomized prospective study of 268 cases

We compared 2 types of cannulated hip screws in a randomized prospective study of 268 femoral neck fractures. Complications were defined as penetration of the screw into the joint, early redisplacement, nonunion or segmental collapse. During the first year, complications were noted in 31 of 130 patients treated with 3 Richards screws and in 34 of 138 patients treated with 2 Uppsala screws. Secondary arthroplasty was performed in 17 cases in the Richards group and in 16 cases in the Uppsala group. Clinical outcome did not differ between the groups.

Percutaneous cannulated screw fixation of femoral neck fractures: the three point principle

Out of a total of 183 patients with displaced intracapsular fractures of the femoral neck, 40 were treated with percutaneous cannulated screw fixation according to the 'three point principle'. These patients were reviewed retrospectively, paying special attention to mechanical failure. Thirty-five fractures healed in a good position. Four fractures (10 per cent) showed signs of recurrent instability, resulting in non-union in two and malunion in one. In all four cases of mechanical failure faults in the operative technique or indication could be established. We conclude that percutaneous cannulated screw fixation is a promising method. However, the right indication and a precise operating technique are important.

Sequential scintigraphy and orthoradiographic measurement of femoral shortening after femoral neck fracture

The objective of the study was to assess scintigraphic patterns and femoral shortening after femoral neck fracture in order to select predictive parameters for late complications. Eighty-eight patients with osteosynthesized femoral neck fractures were followed for 2 years with regular scintigraphic evaluations and orthoradiographic measurements of femoral length shortening. Four different patient categories were identified with regard to the late outcome two different groups with uneventful healing and two different groups with late complications. Accordingly, a high scintigraphic uptake at 1 month may either point to an uneventful healing if combined with minor femoral shortening or indicate failure if combined with a high degree of femoral shortening. In contrast, low scintigraphic uptake may either reflect primary fracture healing if accompanied by minor femoral shortening or predict failure if a high degree of femoral shortening is present. Compared with using scintigraphy alone, combined scintigraphic evaluation and assessment of femoral shortening increased the accuracy for prediction of late failures from 80% to 93%. Early scintigraphic patterns after osteosynthesis of femoral neck fractures have to be validated with care. Radiographic assessment of femoral shortening, which is less invasive, gives better prognostic accuracy and should therefore be preferred for this purpose.

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.

In vitro femoral stiffness after femoral neck osteotomy and osteosynthesis with defined surgical errors

In our search for an osteosynthesis device that would tolerate the surgical errors of the inexperienced surgeon, we tested in vitro femoral stiffness in 75 human osteoporotic femora after internal fixation of a cervical neck osteotomy using three commonly used devices: two von Bahr screws (A. Ericsson AB, Sweden), two cannulated screws (Uppsala type, Olmed AB, Sweden), and two hookpins (LiH, PSAB, Sweden). The first device has its main grip in the cancellous bone by threads; the second has grip in cancellous and subchondral bone by threads; and the third, which has no threads, has its grip in cancellous bone by a hook pin. The intact specimen was in all instances stiffer (22-63%) than the osteosynthesized specimen (p < 0.001). An osteosynthesized femur with perfectly reduced bone ends was 14-23% stiffer than when reduction of the bone ends was insufficient, irrespective of device malposition (p < 0.001). Insufficient reduction of the osteotomy leaving a 20 degrees dorsal angulation of the femoral head combined with too far ventrally placed screws resulted in the lowest femoral stiffness. If reduction of osteotomy was sufficient, screws placed too far ventrally or converging screws did not result in decreased stiffness compared with optimal screw placement. Irrespective of the quality of reduction, osteosynthesis with the Uppsala screw resulted in all instances in a higher stiffness than using the other devices (p < 0.01). With the Uppsala screw design, femoral stiffness after optimal osteosynthesis was reduced by 22% compared with the intact femur, and in the most unfavorable position with combined malreduction and malpositioning it was reduced by 42%. Corresponding values for the von Bahr screws were 29% and 46%, respectively, and for the LiH screws 47% and 63%, respectively. Use of a device with threads and grip in the subchondral bone is recommended for fixation of femoral neck fractures in osteoporotic bone. Furthermore, the importance of anatomical reduction for fracture fixation is emphasized.

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.

Intracapsular fractures of the femoral neck. Results of cannulated screw fixation

The results of stabilization of an intracapsular fracture of the femoral neck with cannulated screws placed in parallel in 141 patients between 1980 and 1985 were reviewed retrospectively. Fifty patients (35 per cent) had a non-displaced fracture (Garden Stage I or II) and ninety-one (65 per cent) had a displaced fracture (Garden Stage III or IV). The median age of the patients was sixty-eight years (range, twenty-four to ninety-five years). The mean duration of follow-up was eight years. No patient died or had a wound infection during the stay in the hospital. Twenty-nine patients, who had a median age of seventy-five years (range, fifty-six to ninety-five years), died within sixty months after treatment; eleven of them (median age, seventy-five years [range, sixty-five to eighty-six years]) died within the first twelve months. There was a loss of position or a non-union of the fracture in five patients (4 per cent) and healing of the fracture in 136 patients (96 per cent). Thirteen patients (11 +/- 3 per cent) had histological or roentgenographic evidence of osteonecrosis within twenty-four months after treatment. Ten of these patients had had a displaced fracture. Osteonecrosis developed in thirteen additional patients during the remaining period of follow-up. Eight of these patients had had a displaced fracture. The prevalence of osteonecrosis at the time of the most recent follow-up (mean duration, eight years) was 22 +/- 4 per cent. Osteonecrosis developed in eight of the forty-one patients who had had a Garden Stage-II fracture, in six of the thirty patients who had had a Garden Stage-III fracture, and in twelve of the forty patients who had had a Garden Stage-IV fracture. The fifty-five surviving patients in whom the fracture healed without complications were found to be functioning well more than sixty months after the fracture.

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.

Fractures in older persons

Fractures in the elderly, especially hip fractures, have increased during recent decades in the west. Due to their large number, and often extended demands on hospital resources, older persons with hip fractures make heavy demands on health care resources. The fractures are the result of both increasing skeletal fragility and increasing falling tendency with age. Preventive measures consist primarily of opposing the sedentary life style of modern society. A continued moderate physical activity since youth, combined with sufficient access to calcium and vitamin D, builds up and retains enough bone stock to resist the decay of 1-2% per year that starts from the fifth decade of life onwards. Falling accidents are probably easier to prevent by training of muscular activity and balance compared to the osteoporosis, which needs a long preventive perspective. The rehabilitation prognosis for the individual patient has greatly improved over recent years.

Prospective comparison of hip fracture treatment. 856 cases followed for 4 months in The Netherlands and Sweden

In a prospective multicenter study 1115 hip fracture patients were registered in Rotterdam (The Netherlands), Sundsvall and Lund (Sweden). The patients had similar background parameters with a mean age of 78 years, about half of them living alone and just above 80 percent coming from independent living. For cervical fracture, hemiarthroplasty was the predominating treatment in Rotterdam (n 169), whereas osteosynthesis was used in Sundsvall (screws n 135) and Lund (hook-pins n 148). The mean (median) hospitalization time was 32 (20) days in Rotterdam, 16 (12) days in Sundsvall, and 17 (10) days in Lund. Discharge to independent living varied from 53 percent in Lund to 72 percent in Sundsvall. Functional outcome (walking ability and ADL capacity) was at 4 months similar in all groups, but at 2 weeks was lower in Rotterdam. Mortality at 2 weeks/1 month/4 months was in Rotterdam 4/9/20, in Sundsvall 2/4/13, and in Lund 0/3/10 percent. Trochanteric fractures were treated by screwplate in Rotterdam (n 146) and Lund (n 78), and by Ender nails in Sundsvall (n 117). The mean (median) hospitalization time was in Rotterdam 39 (29) days, in Sundsvall 24 (15) days and in Lund 19 (11) days. Discharge to independent living varied from 41 percent in Lund to 57 percent in Sundsvall. Functional outcome was similar between the groups. Mortality at 2 weeks/1 month/4 months was in Rotterdam 2/6/14, in Sundsvall 6/12/19 and in Lund 12/12/18 percent. Thus, our study has shown that it is possible to perform a prospective multicenter study involving different European countries.(ABSTRACT TRUNCATED AT 250 WORDS)

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.