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Fracture mapping of adult femoral neck fractures with three dimensional computed tomography. INTERNATIONAL ORTHOPAEDICS 2023; 47:1323-1330. [PMID: 36856859 DOI: 10.1007/s00264-023-05742-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 02/20/2023] [Indexed: 03/02/2023]
Abstract
PURPOSE Femoral neck fractures (FNFs) are a commonly encountered injury in orthopaedic practice. It is essential that surgeons recognize specific fracture patterns to effectively manage these fractures. The purpose of this study was to analyze the fracture morphology of FNFs by three-dimensional (3D) mapping of the fracture. METHODS The fracture line location and distribution of 120 FNFs were identified using computed tomography reconstructions. After segmentation and virtual reduction, the fracture line was revealed. The femoral neck region was divided into zones according to anatomical localization, and the zones through which the fracture lines passed were recorded. All fracture lines are superimposed on the standard model to create fracture mapping. RESULTS A total of 120 patients with FNFs were analyzed. The mean age of the patients was 67 (18-96) years. Of all patients, 59 were male, and 61 were female. The most affected region was Zone 4. The least affected region was Zone 6. The displacement in Zone 1 and Zone 4 was found to be significantly higher. The displacement in patients under 65 years was found to be significantly higher. Zone 2 and Zone 5 involvement was significantly higher in patients under 65 years. CONCLUSION The fracture map showed fracture patterns of FNFs. It was found that fracture displacement and transcervical region involvement were more common in patients under 65 years. It was also found that the displacement rate was high in fractures of the subcapital region.
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Ali M, Neo C, Rajeev A, Bhatnagar S. The Role of Frailty Scores to Predict the Outcomes in Non Operative Treatment of Valgus Impacted Neck of Femur Fractures. ACTA MEDICA (HRADEC KRALOVE) 2023; 66:112-116. [PMID: 38511421 DOI: 10.14712/18059694.2024.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
OBJECTIVES The management of valgus-impacted neck of femur fracture is controversial between operative and conservative treatments. This study aimed to investigate the usefulness of the Clinical frailty Score for predicting the prognosis of patients who underwent non-operative treatment for the valgus-impacted neck of femur fracture (NOF). METHODS A single-centred retrospective review of patients admitted with valgus impacted NOF. Data were collected from patients' records, including demographics, Clinical Frailty Score (CFS), Nottingham Hip Fracture Score (NHFS) and Abbreviated Mental Test Score (AMTS). Patients were followed up to 24 months postoperatively. RESULTS Fifty-eight patients who were treated non-operatively with a mean follow-up of 2.6 years met our inclusion criteria. Twenty-nine patients failed the non-operative treatment and required replacement surgeries, while 29 had successful outcomes (50%). There were no differences between the two groups' mean age and gender distributions (P 0.527 and 0.139, respectively). The successful group had significantly higher CFS (P 0.013), worse AMTS and higher mortality risk based on the NHFS (P 0.006 and P < 0.001, respectively). CONCLUSION This study demonstrates that CFS, AMTS and NHFS can be used as predictors when considering non-operative treatment for the valgus-impacted neck of femur fracture. Patients who are frail, demented and high risk based on the NHFS have higher success rates with non-operative treatment.
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Affiliation(s)
- Mohammed Ali
- Department of Trauma and Orthopaedics, Royal Victoria Infirmary, Newcastle, United Kingdom.
| | - Chryssa Neo
- Department of Trauma and Orthopaedics, Gateshead health Foundation NHS Trust, Gateshead, United Kingdom
| | - Aysha Rajeev
- Department of Trauma and Orthopaedics, Gateshead health Foundation NHS Trust, Gateshead, United Kingdom
| | - Sharad Bhatnagar
- Department of Trauma and Orthopaedics, Royal Victoria Infirmary, Newcastle, United Kingdom
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Mandolini M, Brunzini A, Facco G, Mazzoli A, Forcellese A, Gigante A. Comparison of Three 3D Segmentation Software Tools for Hip Surgical Planning. SENSORS (BASEL, SWITZERLAND) 2022; 22:s22145242. [PMID: 35890923 PMCID: PMC9323631 DOI: 10.3390/s22145242] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 07/11/2022] [Accepted: 07/12/2022] [Indexed: 06/01/2023]
Abstract
In hip arthroplasty, preoperative planning is fundamental to reaching a successful surgery. Nowadays, several software tools for computed tomography (CT) image processing are available. However, research studies comparing segmentation tools for hip surgery planning for patients affected by osteoarthritic diseases or osteoporotic fractures are still lacking. The present work compares three different software from the geometric, dimensional, and usability perspectives to identify the best three-dimensional (3D) modelling tool for the reconstruction of pathological femoral heads. Syngo.via Frontier (by Siemens Healthcare) is a medical image reading and post-processing software that allows low-skilled operators to produce prototypes. Materialise (by Mimics) is a commercial medical modelling software. 3D Slicer (by slicer.org) is an open-source development platform used in medical and biomedical fields. The 3D models reconstructed starting from the in vivo CT images of the pathological femoral head are compared with the geometries obtained from the laser scan of the in vitro bony specimens. The results show that Mimics and 3D Slicer are better for dimensional and geometric accuracy in the 3D reconstruction, while syngo.via Frontier is the easiest to use in the hospital setting.
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Affiliation(s)
- Marco Mandolini
- Department of Industrial Engineering and Mathematical Sciences, Università Politecnica delle Marche, Via Brecce Bianche 12, 60131 Ancona, Italy; (A.B.); (A.F.)
| | - Agnese Brunzini
- Department of Industrial Engineering and Mathematical Sciences, Università Politecnica delle Marche, Via Brecce Bianche 12, 60131 Ancona, Italy; (A.B.); (A.F.)
| | - Giulia Facco
- Dipartimento di Scienze Cliniche e Molecolari, Università Politecnica delle Marche, Via Tronto 10/a, Torrette di Ancona, 60126 Ancona, Italy; (G.F.); (A.G.)
| | - Alida Mazzoli
- Department of Materials, Environmental Sciences and Urban Planning, Università Politecnica delle Marche, Via Brecce Bianche 12, 60131 Ancona, Italy;
| | - Archimede Forcellese
- Department of Industrial Engineering and Mathematical Sciences, Università Politecnica delle Marche, Via Brecce Bianche 12, 60131 Ancona, Italy; (A.B.); (A.F.)
| | - Antonio Gigante
- Dipartimento di Scienze Cliniche e Molecolari, Università Politecnica delle Marche, Via Tronto 10/a, Torrette di Ancona, 60126 Ancona, Italy; (G.F.); (A.G.)
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Vinas-Rios JM, Wölm JH, Sellei RM, Ladenburger A. Challenging the dogma to "always operate" acute hip fractures: a proof-of-concept pilot study for nonoperative management of undisplaced femoral neck fractures. Patient Saf Surg 2022; 16:15. [PMID: 35449068 PMCID: PMC9026626 DOI: 10.1186/s13037-022-00324-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 03/23/2022] [Indexed: 11/10/2022] Open
Abstract
Background The notion that all acute hip fractures are a surgical entity requiring either surgical fracture fixation or hip replacement represents a historic dogma, particularly within the orthopaedic community of the United States. The present study from a European regional trauma center was designed to challenge the notion that stable and undisplaced femoral neck fractures represent an absolute indication for surgical management. Methods The purpose of this study was to investigate the hypothesis that stable and undisplaced femoral neck fractures of the Garden types 1 and 2 can be safely managed nonoperatively. A retrospective observational cohort study was carried out at a regional orthopaedic trauma center in Germany from January 1, 2016 to June 30, 2021. The inclusion criteria specified patients older than 18 years suffering a < 24 h, traumatic, femoral neck fracture Garden types 1 and 2. Exclusion criteria included Garden types 3 and 4 femoral neck fractures, pregnancy, active infection or previous surgery, tumor-associated fractures, medical history of femoral neck necrosis, vascular injury associated with femoral neck fractures, nerve injury associated to a femoral neck fracture and ≥ 24 h femoral neck fracture. The primary intention of this research was to identify deterioration of fracture retention with an ensuing unplanned trip to the operating room in femoral neck fractures Garden types 1 and 2. Secondary were included unplanned readmissions and complications such as surgical site infection. Results A total of 41 undisplaced femoral neck fractures (Garden types 1 and 2) were included in this study; n = 20 were in the resulting admission operatively treated (group 1) and n = 21 were treated conservatively. The mean age in group 1 was 76 years; women (70%). In group 2 it was 81 years with a female dominance (71.4%). Admission status: Garden types 1 and 2, group 1 n = 13/7 and group 2 n = 15/6. Subsequent femoral neck fracture displacement (Y/N) (in case of operation, before operation) group 1 n = 14/6 and group 2 n = 6/15. Conclusion According with our results, patients sustaining Garden type 1 femoral neck fractures, depending on age and comorbidities, should be treated conservatively with weight bearing and under physiotherapeutic instructions. In case of femoral neck fractures Garden type 2, a surgical treatment should be performed in order to avoid femoral neck fractures to slip after weight bearing by lacking of fracture impaction.
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Affiliation(s)
- Juan Manuel Vinas-Rios
- Department of Orthopaedics and Traumatology Sana Klinikum Offenbach, Offenbach am Main, Germany. .,Department of Orthopaedics and Traumatology, Sanaklinik Offenbach am Main, Starkenburgring 66, 63069, Offenbach am Main, Germany.
| | - Jan-Henning Wölm
- Department of Orthopaedics and Traumatology Sana Klinikum Offenbach, Offenbach am Main, Germany
| | - Richard Martin Sellei
- Department of Orthopaedics and Traumatology Sana Klinikum Offenbach, Offenbach am Main, Germany
| | - Andreas Ladenburger
- Department of Orthopaedics and Traumatology Sana Klinikum Offenbach, Offenbach am Main, Germany
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Rogers NB, Karam WN, Kumaravel M, Warner SJ, Gary JL. Dual-Energy CT to Diagnose Occult Femoral Neck Fracture in MRI-Contraindicated Patient: A Case Report. JBJS Case Connect 2021; 11:01709767-202112000-00013. [PMID: 34648465 DOI: 10.2106/jbjs.cc.21.00404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 79-year-old woman presented after a ground level fall with the inability to bear weight on her right hip. Radiographs and computed tomography (CT) imaging were negative for a femoral neck fracture. Her medical comorbidities precluded magnetic resonance imaging (MRI), so dual-energy CT with focused evaluation for bone edema was performed, identifying a femoral neck fracture that was stabilized surgically. CONCLUSION Dual-energy CT with processing for edema can successfully identify nondisplaced femoral neck fractures in MRI-contraindicated patients. This imaging modality could be useful for diagnosing femoral neck stress fractures and ipsilateral femoral neck fractures in patients sustaining high-energy femoral shaft fractures.
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Affiliation(s)
- Nathan B Rogers
- Orthopaedic Surgery Resident, McGovern Medical School at UTHealth Houston, Houston, Texas
| | - Wade N Karam
- Orthopaedic Surgery Resident, McGovern Medical School at UTHealth Houston, Houston, Texas
| | - Manickam Kumaravel
- Department of Radiology, McGovern Medical School at UTHealth Houston, Houston, Texas
| | - Stephen J Warner
- Orthopaedic Trauma Service, McGovern Medical School at UTHealth Houston, Houston, Texas
| | - Joshua L Gary
- Orthopaedic Trauma Service, Keck Medical Center of University of Southern California, Los Angeles, California
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Xu DF, Bi FG, Ma CY, Wen ZF, Cai XZ. A systematic review of undisplaced femoral neck fracture treatments for patients over 65 years of age, with a focus on union rates and avascular necrosis. J Orthop Surg Res 2017; 12:28. [PMID: 28187745 PMCID: PMC5301374 DOI: 10.1186/s13018-017-0528-9] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 02/03/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It remains unclear whether conservative treatment should be used to treat the common undisplaced femoral neck fractures that develop in the elderly. Herein, we systematically review the rates of union and avascular necrosis after conservative and surgical treatment of undisplaced femoral neck fractures. METHODS We searched the EMBASE, PubMed, OVID, Cochrane Library, Web of Science, and Scopus databases for randomized controlled trials or observational studies that assessed the outcomes of conservative or surgical treatments of undisplaced femoral neck fractures. No language or publication year limitation was imposed. Statistical analyses were performed with the aid of the chi-squared test. We evaluated the quality of each publication and the risk of bias. RESULTS Twenty-nine studies involving 5071 patients were ultimately included; 1120 patients were treated conservatively and 3951 surgically. The union rates were 68.8% (642/933) and 92.6% (635/686) in the former and latter groups, respectively (p < 0.001). The avascular necrosis rate in the conservatively treated group was 10.3% (39/380), while it was 7.7% (159/2074) in the surgically treated group (p = 0.09). CONCLUSIONS Surgery to treat undisplaced femoral neck fractures was associated with a higher union rate and a tendency toward less avascular necrosis than conservative treatment.
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Affiliation(s)
- Dan-Feng Xu
- Department of Orthopaedic Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Jie-fang Road 88, Hangzhou, 310009, People's Republic of China
| | - Fang-Gang Bi
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450001, People's Republic of China
| | - Chi-Yuan Ma
- Department of Orthopaedic Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Jie-fang Road 88, Hangzhou, 310009, People's Republic of China
| | - Zheng-Fa Wen
- Department of Orthopaedic Surgery, The Fourth Affiliated Hospital, School of Medicine, Zhejiang University, Yiwu, 322000, People's Republic of China
| | - Xun-Zi Cai
- Department of Orthopaedic Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Jie-fang Road 88, Hangzhou, 310009, People's Republic of China.
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Fu X, Xu GJ, Li ZJ, Du CL, Han Z, Zhang T, Ma X. Three-Dimensional Reconstruction Modeling of the Spatial Displacement, Extent and Rotational Orientation of Undisplaced Femoral Neck Fractures. Medicine (Baltimore) 2015; 94:e1393. [PMID: 26426607 PMCID: PMC4616870 DOI: 10.1097/md.0000000000001393] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The purpose of this study was to employ a new three-dimensional (3D) reconstruction and modeling method to measure displacement of undisplaced femoral neck fractures (Garden stages I and II). We also aimed to evaluate the effectiveness of the Garden classification for determining the displacement of undisplaced femoral neck fractures. A total of 120 consecutive patients with undisplaced femoral neck fractures were enrolled between 2012 and 2014, including 60 within the Garden I group and 60 within the Garden II group. The displacements of the femoral head center (d1) and the lowest point of the fovea capitis femoris (d2) and rotational displacement of the femoral head (α) in the 3D model were measured with 3D computed tomography reconstruction and modeling. Five observers, trauma surgeons, were asked to found the centers of the femoral heads and the deepest points of the foveae. The intraobserver and inter-observer agreements were calculated using Fleiss' kappa. The inter-observer and intra-observer kappa values were 0.937 and 0.985, respectively. Current method has good reliability. We discovered that many participants in our study had been misclassified by an anterior-posterior radiograph as having an "incomplete" fracture. In incomplete fracture of Garden stage I group, the average displacements d1 and d2 were 3.69 ± 1.77 mm and 14.51 ± 1.91 mm, respectively. The mean α was 4.91° ± 2.49°. For impacted fracture of Garden stage I, significant spatial displacement in the impacted fractures was observed (d1: 6.22 ± 3.36 mm; d2: 10.30 ± 5.73 mm; and α: 17.83° ± 10.72°). Similarly, significant spatial displacement was observed among the Garden stage II group (d1: 7.16 ± 4.58 mm; d2: 12.95 ± 8.25 mm; and α: 18.77° ± 9.10°). There was no significant difference in α, d1, and d2 between impacted fracture and Garden stage II groups (P > 0.05). However, significant differences were found between incomplete fracture and Garden stage II groups (P < 0.05). Our findings suggest that 3D reconstruction and modeling may be a better tool for assessing femoral neck fractures than the Garden classification. Undisplaced femoral neck fractures showed variable degrees of displacement and were not undisplaced, stable fractures. Garden classification for undisplaced femoral neck fractures has certain limitations.
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Affiliation(s)
- Xin Fu
- From the Department of Orthopedics, Tianjin Hospital, Tianjin, P.R. China (XF, G-JX, ZH); Department of Orthopedics, General Hospital of Tianjin Medical University, Tianjin, P.R. China (Z-JL, TZ); and Department of Orthopedics, Binzhou Medical University Hospital, Shandong, P.R. China (C-LD)
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Factors predicting secondary displacement after non-operative treatment of undisplaced femoral neck fractures. Arch Orthop Trauma Surg 2015; 135:243-249. [PMID: 25550094 DOI: 10.1007/s00402-014-2139-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION We quantified the risk and the time of occurrence of secondary fracture displacement in non-operatively treated femoral neck fractures in our clinic, as well as investigated potential predicting patient- and fracture-related factors. METHODS The records of 593 patients with femoral neck fractures from January 2000 to December 2009 were reviewed. Sixty-one patients [mean age 83.0 years (SD 9.9)] with undisplaced femoral neck fractures initially received non-operative treatment. The occurrence and the time of secondary fracture displacement were documented, as well as demographics and radiological parameters. Radiographs were evaluated independently by two surgeons. Multivariable regression and Kaplan-Meier survival analyses were used. RESULTS Thirty-four (55.7 %) fractures showed secondary displacement occurring within the first 12 weeks after initiation of non-operative treatment. Twenty (38 %) fractures originally classified as Garden I were found to be Garden II. The risk of secondary displacement was three times higher (RR = 2.8; 95 % CI 1.7-4.8, p < 0.001) for these fractures in comparison with those confirmed as Garden I. Patients with a history of previously diagnosed osteoporosis were at a higher risk of secondary displacement as well (RR = 1.3; 95 % CI 1.0-1.5). CONCLUSIONS Non-operative treatment of femoral neck fractures is a treatment option, but only in well-selected cases. The majority of secondary displacements were associated with initial misdiagnosis using the Garden classification. For Garden II, primary surgical treatment is likely a better option, and therefore careful application of the Garden classification in this context is essential.
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Kim YC, Lee JY, Song JH, Oh S. The Result of In Situ Pinning for Valgus Impacted Femoral Neck Fractures of Patients over 70 Years Old. Hip Pelvis 2014; 26:263-8. [PMID: 27536591 PMCID: PMC4971403 DOI: 10.5371/hp.2014.26.4.263] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 10/07/2014] [Accepted: 10/10/2014] [Indexed: 11/24/2022] Open
Abstract
Purpose We aimed to evaluate the outcome of fixation with cannulated screws for valgus impacted femoral neck fractures in patients over 70 years of age. Materials and Methods We reviewed the outcome in 33 patients older than 70 years with valgus impacted femoral neck fractures who were treated with cannulated screws fixation from May 2007 to December 2010. These patients were followed for at least a year. We assessed the fixation failure rate, body mass index (BMI), bone mineral density (BMD) of proximal femur, distance between screw tip and joint, number of screws and time from fracture to operation. Results We identified six patients (18.2%) with failure. Two patients with subtrochanteric fractures through the screw insertion site and another patient with osteonecrosis were excluded from the fixation failure group. No difference was found in age, BMI, BMD of proximal femur, distance between screw tip and joint, number of screws and time from fracture to operation between failure and non-failure groups. Conclusion The failure rate of cannualted screw fixation for valgus impacted femoral neck fractures in the elderly patients was not low. Risk of failure should be considered in the management of these patients and accurate assessment for fracture type should be performed using computed tomogram and clinical evaluation.
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Affiliation(s)
- Yoon-Chung Kim
- Department of Orthopedic Surgery, The Catholic University of Korea, St. Vincent's Hospital, Suwon, Korea
| | - Joo-Yup Lee
- Department of Orthopedic Surgery, The Catholic University of Korea, St. Vincent's Hospital, Suwon, Korea
| | - Joo-Hyoun Song
- Department of Orthopedic Surgery, The Catholic University of Korea, St. Vincent's Hospital, Suwon, Korea
| | - Seungbae Oh
- Department of Orthopedic Surgery, The Catholic University of Korea, St. Vincent's Hospital, Suwon, Korea
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Du CL, Ma XL, Zhang T, Zhang HF, Wang CG, Zhao F, Ma JX, Fu X, Li ZJ. Reunderstanding of garden type I femoral neck fractures by 3-dimensional reconstruction. Orthopedics 2013; 36:820-5. [PMID: 23746022 DOI: 10.3928/01477447-20130523-31] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Garden type I fractures include incomplete fractures and impacted fractures. With advances in scientific technology and medical treatment, certain deficiencies of the Garden classification have become apparent. The authors hypothesized that the incidence of incomplete femoral neck fractures was low and that impacted femoral neck fractures were not undisplaced and stable fractures. A new method was developed to precisely measure the spatial displacement of the femoral head in impacted femoral neck fractures. Between 2008 and 2011, nine hundred sixty-six patients with femoral neck fractures were treated, 48 of whom had Garden type I fractures, as seen on anteroposterior radiographs. Seven fractures were classified as incomplete on radiographs; however, after 3-dimensional reconstruction, 3 were classified as incomplete and 4 as complete fractures. Furthermore, the remaining 41 Garden I fractures that were classified as impacted on radiographs showed large spatial displacement on 3-dimensional reconstruction. The average rotational displacement of the femoral head was 19.29°±10.51°, and the average displacements of the femoral head center and the lowest point of the fovea capitis were 8.76±4.45 and 14.39±8.08 mm, respectively. This study showed that the incidence of incomplete femoral neck fractures was low. Impacted femoral neck fractures showed variable degrees of displacement and were not undisplaced, stable fractures. Garden classification for impacted femoral neck fractures has certain limitations. Impacted femoral neck fractures should be differentiated from Garden type I fractures so clinicians can select appropriate treatments for these fractures.
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Affiliation(s)
- Chang-Ling Du
- Department of Orthopedics, General Hospital of Tianjin Medical University, Tianjin 300052, PR China
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