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Hua Z, Zhang X, Li X, Wang J, Chen Y, Wang N, Chen Y. Association between surgical delays for femoral neck fractures and early postoperative complications in young and middle-aged adults: A study based on the national inpatient sample database. Injury 2024; 55:111690. [PMID: 39002323 DOI: 10.1016/j.injury.2024.111690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 06/05/2024] [Accepted: 06/17/2024] [Indexed: 07/15/2024]
Abstract
BACKGROUND Femoral neck fractures (FNF) in young and middle-aged adults are primarily caused by high-energy injuries in traffic accidents. Surgical delays often occur due to transportation issues, preoperative evaluations, and economic burdens. METHODS A retrospective analysis was conducted on young and middle-aged FNF patients undergoing reduction and internal fixation surgeries from 2010 to 2019 with the use of the National Inpatient Sample database. Logistic regression analysis was used to assess the relationship between surgical delays and complications, and the independent risk factors contributing to delays. Categorical variables were investigated via a chi-square test, while continuous variables including Elixhauser Comorbidity Index (ECI) scores, length of hospital stay (LOS), and total medical costs were analyzed via t-test or rank-sum test. RESULTS 9,204 patients undergoing reduction and internal fixation surgeries were included. In the delayed group, patients had higher ECI scores, longer hospital stays, higher expenses, and increased inpatient mortality (1.61% vs. 0.28 %, P < 0.0001). Longer surgical delays were associated with higher risks of complications, including femoral head osteonecrosis, internal fixation loosening and breakage, and respiratory complications. Fluid and electrolyte disorders, metastatic cancer, pulmonary circulation disorders, and renal failure were identified as independent risk factors for surgical delays. Except for anemia (OR=2.37, P < 0.0001), no significant differences in early postoperative complications were found between open-reduction and closed-reduction internal fixation (ORIF/CRIF) surgeries. CONCLUSION Early surgical intervention, within a 2-days period after injury, seems to be crucial for young adults with FNF. If CRIF is challenging in some cases, ORIF can be another choice.
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Affiliation(s)
- Zhixun Hua
- Department of Orthopedic Surgery, The First People's Hospital of Foshan, Foshan, Guangdong, 528000, China
| | - Xishun Zhang
- Department of Orthopedic Surgery, The First People's Hospital of Foshan, Foshan, Guangdong, 528000, China; The Seventh Affiliated Hospital, Southern Medical University, Foshan, Guangdong, 528000, China
| | - Xiaodan Li
- Department of Orthopaedics, Nanfang Hospital Zengcheng Campus, Southern Medical University, Guangzhou, Guangdong, 510515, China
| | - Jian Wang
- Department of orthopaedic surgery, Division of orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, China
| | - Yuhang Chen
- Department of Orthopedic Surgery, The First People's Hospital of Foshan, Foshan, Guangdong, 528000, China; Department of orthopaedic surgery, Division of orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, China
| | - Ning Wang
- School of Nursing, Southern Medical University, Guangzhou Avenue North 1838, Baiyun Area, Guangzhou, Guangdong, 510515, China
| | - Yang Chen
- Department of Orthopedic Surgery, The First People's Hospital of Foshan, Foshan, Guangdong, 528000, China.
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Taşcı M, Başak F, Kemah B, Söylemez MS. Analysis of influential factors on surgical outcomes in pediatric femur neck fractures: a single-institution retrospective study. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02584-x. [PMID: 38951157 DOI: 10.1007/s00068-024-02584-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 06/14/2024] [Indexed: 07/03/2024]
Abstract
AIM This retrospective study aimed to evaluate surgical outcomes and identify influential factors in pediatric femoral neck fractures. MATERIALS AND METHODS A total of 25 hips from 23 pediatric patients who underwent surgical intervention for femoral neck fractures were included. Data encompassing patient demographics, fracture types, surgical techniques, complications, and follow-up outcomes were analyzed retrospectively. Factors such as fracture displacement, timing of surgery, fixation methods, and reduction quality were assessed concerning postoperative complications. RESULTS Falling from a height accounted for 48% of the trauma mechanisms, and avascular necrosis (AVN) was the most prevalent complication (4 hips). Although fracture displacement, bad reduction quality, and delayed surgery were more common among complicated cases, statistical significance was not attained. The study noted an association between presence of avascular necrosis and worse clinical results(rho: 0.428, p: 0.05, CI: 95%). CONCLUSION Surgical treatment yielded favorable clinical outcomes; however, limitations due to the study's retrospective design, limited sample size, and single-center approach underscore the necessity for larger multicenter studies. Our findings emphasize the need for comprehensive investigations to better understand and manage pediatric femoral neck fractures, especially regarding factors influencing AVN and long-term outcomes.
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Affiliation(s)
- Murat Taşcı
- Department of Orthopaedics and Traumatology, Umraniye Training and Research Hospital, Istanbul, Türkiye.
| | - Furkan Başak
- Department of Orthopaedics and Traumatology, Umraniye Training and Research Hospital, Istanbul, Türkiye
| | - Bahattin Kemah
- Department of Orthopaedics and Traumatology, Umraniye Training and Research Hospital, Istanbul, Türkiye
| | - Mehmet Salih Söylemez
- Department of Orthopaedics and Traumatology, Umraniye Training and Research Hospital, Istanbul, Türkiye
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3
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Hafez AT, Aly M, Omar I, Richardson G, James K. Does open or closed reduction with internal fixation reduces the incidence of complications in neck of femur fractures in pediatrics: a meta-analysis and systematic review. J Pediatr Orthop B 2024:01202412-990000000-00200. [PMID: 38700872 DOI: 10.1097/bpb.0000000000001186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/06/2024]
Abstract
The neck of femur fracture (FNF) in children is a rare injury with a high incidence of complications such as avascular necrosis (AVN), coxa-vara and nonunion. The aim of this review is to compare the incidence of complications between open reduction with internal fixation (ORIF) and closed reduction with internal fixation (CRIF) of FNF in children. Two independent reviewers searched EMBASE, MEDLINE, COCHRANE and PUBMED databases from inception until April 2022 according to the preferred reporting items for systematic reviews and meta-analyses guidelines. Studies included comparison of complications between open and closed approaches with fixation of FNF in patients less than 18 years old. Publication bias was assessed using Egger's test while the Newcastle-Ottawa tool was used to assess the methodological quality of the studies. A total of 724 hip fractures from 15 included studies received either ORIF or CRIF. Overall, the rate of AVN was approximately 21.7% without statistical significance between both reduction methods [relative risk (RR) = 0.909, using fixed effect model at 95% confidence interval (CI, 0.678-1.217)]. No significant heterogeneity among AVN studies ( I2 = 3.79%, P = 0.409). Similarly, neither coxa-vara nor nonunion rates were statistically significant in both treatment groups (RR = 0.693 and RR = 0.506, respectively). Coxa-vara studies showed mild heterogeneity ( I2 = 27.8%, P = 0.218), while significant publication bias was encountered in nonunion studies ( P = 0.048). No significant difference in the incidence of AVN, coxa-vara and nonunion between ORIF or CRIF of FNF in children. High-quality studies as Randomised Controlled Trials can resolve the inconsistency and heterogeneity of other risk factors including age, initial displacement, fracture type, reduction quality and time to fixation.
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Affiliation(s)
- Ahmed T Hafez
- University College London Hospitals NHS Foundation Trust
- The Blizard Institute Centre for Trauma Sciences, Queen Mary University of London Barts and the London School of Medicine and Dentistry, London
| | - Mohammed Aly
- University College London Hospitals NHS Foundation Trust
- The Blizard Institute Centre for Trauma Sciences, Queen Mary University of London Barts and the London School of Medicine and Dentistry, London
| | - Islam Omar
- Antrim Area Hospital, Northern Health and Social Care Trust, Antrim
| | | | - Kyle James
- The Blizard Institute Centre for Trauma Sciences, Queen Mary University of London Barts and the London School of Medicine and Dentistry, London
- University Hospitals Sussex NHS Foundation Trust, Brighton, UK
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Abdel-Wahed M, Elmahdy Ismail M, Galal AA, Elsary AY, Abdel-Ghani H, Yasin E. Open versus closed reduction and internal fixation in children with femoral neck fractures. Systematic review and meta-analysis of the literature. J Orthop 2024; 51:157-162. [PMID: 38405127 PMCID: PMC10891281 DOI: 10.1016/j.jor.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 02/09/2024] [Indexed: 02/27/2024] Open
Abstract
Background Femoral neck fractures in children are uncommon, making up little more than 1% of all paediatric fractures. It's not apparent which type of internal fixation-closed or open-is preferable in these situations when it comes to therapeutic options. When treating children with displaced femoral neck fractures, serious problems can arise. Methods Five databases were examined: Medline Plus, PubMed, Scopus, Science Direct, and Web of Science. The outcomes that were relevant for the meta-analysis were non-union, coxa vara, and avascular necrosis. Using the RevMan file, we extracted the data and carried out the analysis (Review Manager Version 5.3). Results 294 patients had ORIF procedures and 266 patients had CRIF procedures in the included trials. Regarding the outcome of avascular necrosis, we discovered that there was no statistically significant difference between the two groups (RR = 0.84, [95% confidence range (CI) = 0.60, 1.18], P = 0.32). There was homogeneity in the data (P = 0.22, I2 = 27%). When it came to coxa vara, there was no statistically significant difference between the two groups (RR = 0.69, [95% CI = 0.30, 1.58], P = 0.38). There was homogeneity in the data (P = 0.22, I2 = 27%). Regarding non-union, the similar outcome was seen (RR = 0.45, [95% CI = 0.16, 1.14], P = 0.12). There was homogeneity in the data (P = 0.49, I2 = 0%). Conclusion Regarding reducing the risk of non-union, coxa vara, and avascular necrosis, we did not find any difference between CRIF and ORIF. To validate this outcome, however, additional research on the various variables (fracture type, age, displacement, fixation technique, and duration of surgery) is required. Sorting patients based on the kind of fracture will ensure that the right approach is used for each type.
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Affiliation(s)
- Mohamed Abdel-Wahed
- Department of Medicine Cairo University, Kasr A Ainy St, Cairo, 11562, Egypt
| | | | - Ahmed Amin Galal
- Department of Medicine Cairo University, Kasr A Ainy St, Cairo, 11562, Egypt
| | - Asmaa Younis Elsary
- Faculty of Medicine, Fayoum University, Gamma St., Keman Square, 63514, Fayoum, Egypt
| | - Hisham Abdel-Ghani
- Department of Medicine Cairo University, Kasr A Ainy St, Cairo, 11562, Egypt
| | - Ebeed Yasin
- Faculty of Medicine, Aswan University, Aswan, New Aswan City, 81528, Egypt
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Kumar I, Ahmed W, Roshan R, Kumar S, Bhadani JS. Traumatic bilateral neck of femur fracture in paediatric age: A case report and review of literature. Med J Armed Forces India 2023; 79:S307-S310. [PMID: 38144665 PMCID: PMC10746796 DOI: 10.1016/j.mjafi.2022.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 01/13/2022] [Indexed: 10/18/2022] Open
Abstract
Bilateral femoral neck fractures are rare, and only a few cases have been reported following major trauma in children. An 8-year-old male patient presented with pain both hips and inability to bear weight on his lower limbs, four days after he fell through a roof while playing. The anteroposterior pelvic radiograph showed a displaced transcervical fracture of the right femoral neck and an undisplaced transcervical fracture of the left femoral neck. Operative fixation of both hips with cannulated cancellous screws done on the 5th day of injury led to a successful outcome. This case is presented due to its rarity and successful outcome despite a late presentation.
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Affiliation(s)
- Indrajeet Kumar
- Assistant Professor (Orthopaedics), Indira Gandhi Institute of Medical Science, Sheikhpura, Patna, Bihar, India
| | - Wasim Ahmed
- Associate Professor (Orthopaedics), Indira Gandhi Institute of Medical Science, Sheikhpura, Patna, Bihar, India
| | - Reetesh Roshan
- Junior Resident (Orthopaedics), Indira Gandhi Institute of Medical Science, Sheikhpura, Patna, Bihar, India
| | - Santosh Kumar
- Professor & Head (Orthopaedics), Indira Gandhi Institute of Medical Science, Sheikhpura, Patna, Bihar, India
| | - Janki Sharan Bhadani
- Senior Resident (Orthopaedics), Indira Gandhi Institute of Medical Science, Sheikhpura, Patna, Bihar, India
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Qi BH, Wang XW, Wang XM, Wang H, Yang YT, Jie Q. Risk factors related with avascular necrosis after internal fixation of femoral neck fractures in children: a systematic review and meta-analysis. Front Pediatr 2023; 11:1188179. [PMID: 37601134 PMCID: PMC10433745 DOI: 10.3389/fped.2023.1188179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 07/21/2023] [Indexed: 08/22/2023] Open
Abstract
Background Less than 1% of children develop femoral neck fractures (FNF), making them uncommon. However, they may have dangerous side effects, like avascular necrosis. Even though several risk factors for postoperative avascular necrosis have been identified, there is still debate regarding them. In this investigation, a meta-analysis was performed to examine the potential causes of postoperative avascular necrosis in children with FNF. Methods We conducted a thorough literature search to find risk factors for avascular necrosis (AVN) after internal fixation of pediatric FNF. Until December 2022, we searched several databases, including PubMed, Embase, Cochrane Library, Web of Science, CNKI, Orthosearch, and Sinomed. Software Zotero 6.0 and Stata 17.0 were used to organise and synthesise the data. Finally, a sensitivity and publication bias test was carried out. Results Our study includes a total of 15 case-control studies involving 814 patients. The risk of postoperative AVN increased with age at fracture encounter (95% CI: 0.64-1.88, P = 0.0003), initial fracture displacement (95% CI: 1.87-9.54, P = 0.0005), and poor fracture reduction (95% CI:1.95-22.34, P = 0.0024) were risk factors for postoperative AVN. There was no significant relationship between gender and postoperative AVN (95% CI: 0.52-1.31, P = 0.41). Conversely, Postoperative AVN and reduction methods have no connection with each other (95% CI: 0.77-2.66, P = 0.25), procedure time (95% CI: 0.43-2.99, P = 0.16), or injury mechanism (95% CI: 0.32-2.26, P = 0.75). The incidence of post-operative AVN varies between Delbet fracture types (95% CI: 0.15-0.31, P < 0.0001), with the overall trend being that the incidence of post-operative AVN is highest for type II, lowest for type IV, and close for types I and III, but it is not clear which type of fracture is the independent risk factor. Funnel plots indicate no significant publication bias. Conclusions In line with this study, About 26% of children who underwent surgery for a femoral neck fracture suffered postoperative AVN. The main risk factors for AVN were the child's age, the initial displacement of the fractures, and poorly reduced fractures. The risk of AVN did not significantly correlate with gender, the time of the procedure, reduction methods or the mechanism of injury. The overall trend in the incidence of postoperative AVN for the different Delbet types of fracture is that the incidence of postoperative AVN is highest for type II, lowest for type IV, and close for types I and III, but it is not clear which type of fracture is the independent risk factor.
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Affiliation(s)
- Bo-Hai Qi
- Pediatric Orthopedic Hospital, Honghui Hospital, Xi’an Jiaotong University, Xi’an, China
- Xi'an Medical University, Xi'an, China
| | - Xiao-Wei Wang
- Pediatric Orthopedic Hospital, Honghui Hospital, Xi’an Jiaotong University, Xi’an, China
| | - Xiao-Ming Wang
- Pediatric Orthopedic Hospital, Honghui Hospital, Xi’an Jiaotong University, Xi’an, China
| | - Huan Wang
- Pediatric Orthopedic Hospital, Honghui Hospital, Xi’an Jiaotong University, Xi’an, China
| | - Ya-ting Yang
- Pediatric Orthopedic Hospital, Honghui Hospital, Xi’an Jiaotong University, Xi’an, China
| | - Qiang Jie
- Pediatric Orthopedic Hospital, Honghui Hospital, Xi’an Jiaotong University, Xi’an, China
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7
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Mishra PK, Jain S, Nadeem M. Three-Year Experience and Outcomes of Near-Early Internal Fixation for Femoral Neck Fractures in Pediatric Trauma Patients: A Retrospective Study. Cureus 2023; 15:e40049. [PMID: 37425594 PMCID: PMC10324986 DOI: 10.7759/cureus.40049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2023] [Indexed: 07/11/2023] Open
Abstract
Background The fractured neck of the femur in children is commonly caused by high-energy trauma, and despite its low incidence, complications are more frequent. Delayed presentation is not unusual in developing countries. The interval between injury and surgery is thought to be a critical factor in determining outcomes. This study aims to evaluate the effectiveness of "near early" internal fixation (24-72 hours) for fractured neck of the femur in children. Methods This is a retrospective observational study that analyzed complete case records from a period of seven years. Cases were classified according to the Delbet classification and outcomes were assessed using the Ratliff criteria with a minimum follow-up of three years. Results The study included 24 male and 11 female patients, with an average age of 11.28 years. The most common cause of injury was road traffic accidents. The fracture distribution in the study population was as follows: Delbet type II in 18 patients, Delbet type III in 10 patients, and Delbet type IV in seven patients. In our study, all patients underwent near-early fixation, meaning their fractures were fixed within 24-72 hours of injury. The average time for the clinical-radiological union was 8 weeks, and the most common complication was premature physeal fusion, followed by osteonecrosis. Conclusion In developing countries, where patients often experience delayed referrals and lack of awareness, near-early fixation (24-72 hours) of a fractured neck of the femur in children is a crucial option that holds significant value.
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Affiliation(s)
- Pankaj K Mishra
- Department of Orthopaedics, All India Institute of Medical Sciences, Bhopal, IND
| | - Siddharth Jain
- Department of Orthopaedics, All India Institute of Medical Sciences, Bhopal, IND
| | - Mohammed Nadeem
- Department of Orthopaedics, Gandhi Medical College, Bhopal, IND
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Lim EJ, Kim BS, Kim M, Shon HC, Kim CH. Open reduction versus closed reduction in internal fixation of displaced femoral neck fracture in children: a systematic review and meta-analysis. J Orthop Surg Res 2023; 18:49. [PMID: 36650541 PMCID: PMC9843841 DOI: 10.1186/s13018-023-03525-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 01/10/2023] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The quality of reduction is an important factor affecting clinical outcomes for displaced femoral neck fractures (FNFs). However, concerns remain about the invasiveness of open reduction and internal fixation (ORIF) as compared to that of closed reduction and internal fixation (CRIF), and the choice between ORIF and CRIF as an optimal treatment strategy for displaced pediatric FNF remains controversial. MATERIALS AND METHODS MEDLINE, Embase, and the Cochrane Library were systematically searched for studies published up to December 22, 2022, that compared ORIF and CRIF techniques for treating FNF in children. Pooled analysis identified differences in surgical outcomes between ORIF and CRIF, especially regarding postoperative complications, such as osteonecrosis of the femoral head (ONFH), nonunion, coxa vara deformity, leg-length discrepancy LLD, and premature physeal closure (PPC). RESULTS We included 15 studies with 635 pediatric FNF cases in our review. Of these, 324 and 311 were treated with ORIF and CRIF, respectively. The pooled analysis revealed that no significant differences existed between each reduction technique for ONFH (odds ratio [OR] = 0.89; 95% confidence interval [CI] 0.51-1.56; P = 0.69), nonunion (OR = 0.51; 95% CI 0.18-1.47; P = 0.21), coxa vara deformity (OR = 0.58; 95% CI 0.20-1.72; P = 0.33), LLD (OR = 0.57; 95% CI 0.18-1.82; P = 0.35), and PPC (OR = 0.72; 95% CI 0.11-4.92; P = 0.74). CONCLUSIONS Despite concerns about the invasiveness of ORIF, no differences in complications exist between ORIF and CRIF after FNF in children. Therefore, we believe that ORIF should be performed in FNF when the fracture is irreducible by closed manner.
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Affiliation(s)
- Eic Ju Lim
- grid.254229.a0000 0000 9611 0917Department of Orthopaedic Surgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
| | - Boo-Seop Kim
- grid.254224.70000 0001 0789 9563Department of Orthopaedic Surgery, Hyundae General Hospital, Chung-Ang University College of Medicine, Namyangju-Si, Kyunggi-Do Republic of Korea
| | - Minboo Kim
- grid.254229.a0000 0000 9611 0917Department of Orthopaedic Surgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
| | - Hyun-Chul Shon
- grid.254229.a0000 0000 9611 0917Department of Orthopaedic Surgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
| | - Chul-Ho Kim
- grid.267370.70000 0004 0533 4667Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-Ro 43-Gil, Songpa-Gu, Seoul, Republic of Korea ,grid.254224.70000 0001 0789 9563Department of Orthopaedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea
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Xin P, Li Z, Pei S, Shi Q, Xiao L. The incidence and risk factors for femoral head necrosis after femoral neck fracture in pediatric patients: a systematic review and meta-analysis. J Orthop Surg Res 2023; 18:22. [PMID: 36624532 PMCID: PMC9830722 DOI: 10.1186/s13018-023-03502-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 01/02/2023] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The incidence of avascular necrosis (AVN) after pediatric femoral neck fracture (PFNF) in the literature varies widely, and the risk factors associated with AVN after PFNF are controversial. Therefore, this study aimed to accurately investigate the incidence of AVN after PFNF and systematically evaluate and meta-classify their risk factors. METHODS A comprehensive search was performed of PubMed, Web of Science, and Embase. The pooled rate and 95% confidence interval (CI) were used to assess the incidence of AVN after PFNF, and pooled odds ratio (OR) were calculated to measure the effect sizes. In addition, we performed subgroup, stratified, and publication bias analyses. RESULTS A total of 30 articles were included in our meta-analysis, with 303 AVN cases among 1185 patients. The pooled incidence of AVN after PFNF was 22% (95% CI 18%, 27%). Subgroup analyses indicated Delbet type I-IV fracture incidences with AVN of 45%, 32%, 17%, and 12%, respectively. The incidence of AVN after PFNF in Asia was 19%, lower than in Africa at 36%, Europe at 26%, and North America at 23%. In addition, the larger sample size group and the earlier published literature group showed a higher incidence of necrosis. Stratified analyses showed that patient age and Delbet fracture classification were both important factors affecting AVN after PFNF (OR = 1.61, p = 0.02 and OR = 3.02, p < 0.001, respectively), while the time to treatment was not (OR = 0.9, p = 0.71). CONCLUSION The pooled incidence of AVN after PFNF was ~ 22%; furthermore, the available evidence demonstrates that patient age and Delbet type of fracture were important influencing factors of AVN after PFNF.
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Affiliation(s)
- Pengfei Xin
- grid.412540.60000 0001 2372 7462Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Ziqi Li
- grid.411866.c0000 0000 8848 7685The Third Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Shaoqiang Pei
- grid.412540.60000 0001 2372 7462Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Qi Shi
- grid.412540.60000 0001 2372 7462Shanghai University of Traditional Chinese Medicine, Shanghai, China ,grid.412540.60000 0001 2372 7462Arthritis Research Institute of Integrated Traditional Chinese and Western Medicine, Shanghai Academy of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Lianbo Xiao
- grid.412540.60000 0001 2372 7462Arthritis Research Institute of Integrated Traditional Chinese and Western Medicine, Shanghai Academy of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China ,grid.412540.60000 0001 2372 7462Department of Orthopedics, Guanghua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, 20000 China
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10
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Wang W, Xiong Z, Li Y, Guo Y, Li M, Mei H, Canavese F, Chen S. Variables influencing radiological fracture healing in children with femoral neck fractures treated surgically: A review of 177 cases. Orthop Traumatol Surg Res 2022; 108:103052. [PMID: 34530130 DOI: 10.1016/j.otsr.2021.103052] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 04/13/2021] [Accepted: 04/23/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE This study aimed: (1) to determine the probability of and the amount of time needed to achieve fracture healing in children with displaced femoral neck fractures (FNFs) treated surgically; and (2) to determine which factors can affect both the probability of and the amount of time needed to achieve radiological fracture healing in those patients. HYPOTHESIS Pediatric FNFs require longer time to achieve union than previously reported. METHODS We retrospectively reviewed the data of 177 children (mean age 10.5±3.9 years) with FNFs treated surgically. Risk factors, including age, sex, laterality, the mechanism of injury, the initial displacement severity, the type of fracture, the time to reduction, the reduction method, the fixation method and the reduction quality, were recorded. Furthermore, the presence of a comminuted medial or posterior cortex on anteroposterior (AP) or lateral radiographs was also recorded. RESULTS A total of 172 hips (97.2%) achieved radiological fracture healing during the follow-up period. Severe initial displacement, a comminuted cortex on the AP or lateral radiographs and poor reduction quality significantly increased the time needed to achieve radiological fracture healing (p<0.05). Cox regression analysis indicated that the cumulative probability of achieving fracture healing increased linearly during the first 6 months and then plateaued, with a monthly increase of less than 5%. The severity of initial displacement, presence/absence of comminution on the medial or posterior cortex, and reduction quality were factors influencing the probability of achieving fracture healing within the first 6 months after injury (p<0.05). CONCLUSIONS Radiological union of displaced pediatric FNFs treated surgically increases linearly during the first six month after surgery and then it tends to plateau. Risk factors for nonunion are severe initial displacement, poor reduction quality and the presence of comminuted medial or posterior cortex on AP or lateral radiographs; the same factors are associated with a longer time to achieve fracture healing. LEVEL OF EVIDENCE III.
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Affiliation(s)
- WenTao Wang
- Scientific Research Center, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Zhu Xiong
- Department of Pediatric Orthopedics, ShenZhen Children's Hospital, Shenzhen, China
| | - YiQiang Li
- Department of Pediatric Orthopaedics, GuangZhou Women and Children's Medical Center, GuangZhou Medical University, Guangzhou, China
| | - YueMing Guo
- Department of Pediatric Orthopaedics, FoShan Hospital of Traditional Chinese Medicine, Foshan, China
| | - Ming Li
- Department of Pediatric Orthopaedics, Children's Hospital of ChongQing Medical University, Chongqing, China
| | - HaiBo Mei
- Department of Pediatric Orthopaedics, HuNan Children's Hospital, Hunan, China
| | - Federico Canavese
- Department of Pediatric Orthopaedics, Lille University Center, Jeanne-de-Flandre Hospital, avenue Eugène-Avinée, 59037 Lille cedex, France
| | - ShunYou Chen
- Department of Pediatric Orthopedics,Fuzhou Second Hospital, Xiamen University, Fuzhou, China.
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Chandankere V, Shah H. Controversies in the management of pediatric neck femur fractures- a systematic review. J Orthop 2021; 27:92-102. [PMID: 34588744 DOI: 10.1016/j.jor.2021.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 07/12/2021] [Accepted: 08/29/2021] [Indexed: 10/20/2022] Open
Abstract
Purpose To review controversies systematically in the management of pediatric neck femur fracture from the literature and to develop consensus for the optimum management. Methods Authors searched literature by using keywords of pediatric neck femur fracture, proximal femur fracture, complications, management by following PRISMA guidelines. A common dilemma was listed. Results Age, mechanism of injury, fracture type, presentation, treatment method, implant, and nature of complications were compared. Inference from recent literature was extracted for optimum management. Conclusion Immediate anatomical reduction with stable fixation must be accomplished. Complications continue to happen despite the best efforts and a longer follow-up is important.
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Affiliation(s)
| | - Hitesh Shah
- Pediatric Orthopaedics Services, Department of Orthopaedics, KMC, Manipal, Manipal Academy of Higher Education, Manipal, 576104, India
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12
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Li Z, Zhuang Z, Hong Z, Chen L, He W, Wei Q. Avascular necrosis after femoral neck fracture in children and adolescents: poor prognosis and risk factors. INTERNATIONAL ORTHOPAEDICS 2021; 45:2899-2907. [PMID: 34549321 DOI: 10.1007/s00264-021-05210-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 09/06/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Avascular necrosis (AVN) after femoral neck fracture (FNF) is a rare and severe paediatric condition, but only few studies described its prognosis and risk factors. The present study aimed to evaluate the outcomes and independent factors for poor prognosis of AVN after FNF in children and adolescents. METHOD This retrospective study included children and adolescents with AVN after FNF who received conservative treatment (CT group) or non-vascularized bone grafting (NVBG group) between 2000 and 2018. The primary outcomes were the risk of hip arthritis (Tönnis grade) and hip deformity risk (Stulberg classification). All patients were followed for at least two years to assess AVN progression. RESULTS Study included 81 patients. In the CT group, 23/43 patients (53.4%) developed hip arthritis, and 24/43 patients (55.8%) showed hip deformity. In the NVBG group, 23/38 patients (60.5%) developed hip arthritis, and 34/38 patients (89.5%) had a hip deformity. The multivariable analysis indicated that NVBG surgery had no significant effect on the outcomes. Post-treatment femoral head collapse (P = 0.05, OR = 3.80, 95% CI = 1.01-14.29) and post-treatment hip subluxation (P = 0.01, OR = 2.85, 95% CI = 2.31-129.56) were independent risk factors for severe hip arthritis. Post-treatment femoral head collapse (P < 0.01, OR = 7.64, 95% CI = 3.23-18.04) and pre-treatment hip subluxation (P = 0.02, OR = 7.33, 95% CI = 1.44-37.41) were independent risk factors for severe hip deformity. CONCLUSION Neither CT nor NVBG have demonstrated superiority regarding long-term outcomes in patients with AVN after FNF. Upon the disease progression to severe collapse with subluxation and severe arthritis, further hip preservation attempts could be futile.
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Affiliation(s)
- Ziqi Li
- Department of Joint Diseases, Traumatology & Orthopedics Institute of Guangzhou University of Chinese Medicine, The Third Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510000, Guangdong, China
| | - Zhikun Zhuang
- Quanzhou Orthopedic-Traumatological Hospital of Fujian Traditional Chinese Medicine University, Quanzhou, 362000, Fujian, China
| | - Zhinan Hong
- Department of Joint Diseases, Traumatology & Orthopedics Institute of Guangzhou University of Chinese Medicine, The Third Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510000, Guangdong, China
| | - Leilei Chen
- Department of Joint Diseases, Traumatology & Orthopedics Institute of Guangzhou University of Chinese Medicine, The Third Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510000, Guangdong, China
| | - Wei He
- Department of Joint Diseases, Traumatology & Orthopedics Institute of Guangzhou University of Chinese Medicine, The Third Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510000, Guangdong, China.
| | - Qiushi Wei
- Department of Joint Diseases, Traumatology & Orthopedics Institute of Guangzhou University of Chinese Medicine, The Third Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510000, Guangdong, China.
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Chaudhary S, Garg V, Mishra D, Yasam R, Barik S, Sinha SK, Singh V. Risk Factors for Avascular Necrosis of the Femoral Head in Pediatric Femoral Neck Fractures. Cureus 2021; 13:e16776. [PMID: 34476143 PMCID: PMC8404535 DOI: 10.7759/cureus.16776] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction A neck of femur fracture is a rare injury in the pediatric population and is of foremost importance, as it is associated with a high rate of complications. It usually occurs due to high-velocity trauma or a fall from a height. There is a scarcity of data on risk factors and their role in the prognostication of avascular necrosis. The purpose of the study was to retrospectively analyze the association of various risk factors with avascular necrosis (AVN) of the femoral head in patients with a neck of femur fracture in the pediatric age group. Material and methods The study included 21 (13 males and 8 females) pediatric patients with a neck of femur fracture treated at a university-level hospital. The patients were followed for a minimum of one year and the clinico-radiological outcome was analyzed using Ratliff criteria. The association of AVN with age, gender, side, fracture type, and injury with treatment delay, type of reduction, and type of internal fixation used was studied. Results The mean age of the treated patients was 11 (±3.178) years (range=5-16 years). Avascular necrosis was seen in four patients and coxa vara occurred in two of them. A statistically significant association was seen between the Delbet fracture type and avascular necrosis, and three out of four cases of AVN were a Type I fracture (p-value=0.006). Three out of six patients having concomitant skeletal or other organ injuries developed AVN (p-value=0.022). The rate of AVN was higher in patients who were managed after 48 hours of initial injury but no statistically significant correlation was found (p-value=0.314). No statistically significant association with AVN was found between gender, age, type of reduction (closed/open), or the implant used (cannulated screws/k-wires). Conclusions Multiple independent factors may have a role in the development of AVN of the femoral head in children. Prognostication should not be based on a single factor. Statistically significant results in this study have shown that the type of fracture and concomitant skeletal or other organ injuries are important risk factors and should be kept in mind. All independent risk factors must be noted and should be considered while prognosticating the outcome of a child with a neck of femur fracture.
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Affiliation(s)
- Sunny Chaudhary
- Orthopaedics, All India Institute of Medical Sciences, Rishikesh, IND
| | - Varun Garg
- Orthopaedics, All India Institute of Medical Sciences, Rishikesh, IND
| | - Dipun Mishra
- Orthopaedics, All India Institute of Medical Sciences, Rishikesh, IND
| | - Ramapriya Yasam
- Orthopaedics, All India Institute of Medical Sciences, Rishikesh, IND
| | - Sitanshu Barik
- Orthopaedics, All India Institute of Medical Sciences, Rishikesh, IND
| | - Sourabh K Sinha
- Orthopaedics, All India Institute of Medical Sciences, Rishikesh, IND
| | - Vivek Singh
- Orthopaedics, All India Institute of Medical Sciences, Rishikesh, IND
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14
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Yang F, Zhuang Z, Tu Y, Hong Z, Pang F, He W, Wei Q, Li Z. Pathological progress of traumatic femur head necrosis after femoral neck fracture in children and adolescents: a case series study. J Hip Preserv Surg 2021; 7:696-704. [PMID: 34377512 PMCID: PMC8349579 DOI: 10.1093/jhps/hnab025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/15/2021] [Indexed: 11/14/2022] Open
Abstract
The pathological progression and prognosis of traumatic femur head necrosis (TFHN) after femoral neck fracture (FNF) in children and adolescent is relatively unknown and has never been specifically characterized. As we speculated, the prognosis in such population would be poor and characterized as the high risk of femoral head collapse, hip deformity and degeneration in a short term. This retrospective case series enrolled 64 children and adolescent with TFHN who treated with observational treatment from 2000.1 to 2018.1. The primary outcomes, the progression of femoral head collapse, hip deformity (Stulberg classification) and hip degeneration (Tönnis grade), and their prognostic factors were analysed. Sixty-four patients with a mean age of 13 years (6-16 years) were included. A total of 28 hips (44%) showed unsatisfactory outcome and 25 (39%) hips collapsed progressively during a mean follow-up of 48 months (24-203 months). Finally, 38 hips (59%) experienced hip deformity, 20 of them were Class IV/V. Thirty-four hips (53%) generally progressed to osteoarthritis, 14 of them were classified as Grades II/III. The location of the lesion and the presence of subluxation were found to be related to progression of collapse; however, the presence of subluxation was the only independent risk factor of severe hip deformity and degeneration. TFHN in children and adolescent is a rapidly progressing disease with a poor prognosis characterized by a high risk of femoral head collapse progression. If the subluxation emerged, collapsed cases showed increasingly tendency towards hip deformity and degeneration.
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Affiliation(s)
- Fan Yang
- Department of Orthopaedics & Traumatology, Lingnan Medical Research Center, Guangzhou University of Chinese Medicine, No.12, airport road, Baiyun distinct, Guangzhou city, Guangdong province, 510000, China
| | - Zhikun Zhuang
- Department of Orthopaedics & Traumatology, Lingnan Medical Research Center, Guangzhou University of Chinese Medicine, No.12, airport road, Baiyun distinct, Guangzhou city, Guangdong province, 510000, China
- Department of Joint Diseases, Quanzhou Orthopedic-traumatological Hospital of Fujian Traditional Chinese Medicine University, No.61, Citong western road, Quanzhou city, Fujian province, 362000, China
| | - Yonggang Tu
- Department of Orthopaedics & Traumatology, Lingnan Medical Research Center, Guangzhou University of Chinese Medicine, No.12, airport road, Baiyun distinct, Guangzhou city, Guangdong province, 510000, China
- Department of Orthopaedics, Dongguan Eastern Central Hospital, No. 88, Changdong Road, Changping Town, Dongguan city, Guangdong province, 510000, China
| | - Zhinan Hong
- Department of Orthopaedics & Traumatology, Lingnan Medical Research Center, Guangzhou University of Chinese Medicine, No.12, airport road, Baiyun distinct, Guangzhou city, Guangdong province, 510000, China
- Department of Joint Diseases, Traumatology & Orthopedics Institute of Guangzhou University of Chinese Medicine, The Third Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou city, Guangdong province, 510000, China
| | - Fengxiang Pang
- Department of Orthopaedics & Traumatology, Lingnan Medical Research Center, Guangzhou University of Chinese Medicine, No.12, airport road, Baiyun distinct, Guangzhou city, Guangdong province, 510000, China
| | - Wei He
- Department of Orthopaedics & Traumatology, Lingnan Medical Research Center, Guangzhou University of Chinese Medicine, No.12, airport road, Baiyun distinct, Guangzhou city, Guangdong province, 510000, China
- Department of Joint Diseases, Traumatology & Orthopedics Institute of Guangzhou University of Chinese Medicine, The Third Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou city, Guangdong province, 510000, China
| | - Qiushi Wei
- Department of Orthopaedics & Traumatology, Lingnan Medical Research Center, Guangzhou University of Chinese Medicine, No.12, airport road, Baiyun distinct, Guangzhou city, Guangdong province, 510000, China
- Department of Joint Diseases, Traumatology & Orthopedics Institute of Guangzhou University of Chinese Medicine, The Third Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou city, Guangdong province, 510000, China
| | - Ziqi Li
- Department of Orthopaedics & Traumatology, Lingnan Medical Research Center, Guangzhou University of Chinese Medicine, No.12, airport road, Baiyun distinct, Guangzhou city, Guangdong province, 510000, China
- Department of Joint Diseases, Traumatology & Orthopedics Institute of Guangzhou University of Chinese Medicine, The Third Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou city, Guangdong province, 510000, China
- Correspondence to: Z. Li. E-mail:
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15
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The clinical features, management options and complications of paediatric femoral fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:883-892. [PMID: 33839930 PMCID: PMC8233277 DOI: 10.1007/s00590-021-02933-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 03/08/2021] [Indexed: 10/27/2022]
Abstract
This article discusses the incidence, applied anatomy and classification of paediatric femoral fractures based on critical appraisal of the available evidence. The aim is to identify techniques that are relevant to contemporary practice whilst excluding the technical details of individual procedures that are beyond the scope of this review. Injuries of the proximal, diaphyseal and distal segments are considered individually as there are considerations that are specific to each anatomical site. Femoral neck fractures are rare injuries and require prompt anatomical reduction and stable fixation to minimise the potentially devastating consequences of avascular necrosis. Diaphyseal fractures are relatively common, and there is a spectrum of management options that depend on patient age and size. Distal femoral fractures often involve the physis, which contributes up to 70% of femoral length. Growth arrest is common consequence of fractures in this region, resulting in angular and length-related deformity. Long-term surveillance is recommended to identify deformity in evolution and provide an opportunity for early intervention. Deliberate injury should be considered in all fractures, particularly distal femoral physeal injuries and fractures in the non-walking child.
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16
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Deng F, Li Z, Liu J. Complications after tibial tubercle traction and femoral neck fractures in children: a case report. Postgrad Med 2021; 133:460-464. [PMID: 33441046 DOI: 10.1080/00325481.2021.1874701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Background: Genu recurvatum and femoral neck fracture in children are very rare, and relevant literaturewas reported. However, there were no reports on avascular necrosisafter internal fixation of femoral neck fractures in children, and genu recurvatum and tibial dysplasia after tibial tubercle traction.Case presentation: In this case, a 32-year-old female patient suffered from a femoral neck fracture at the age of 10. The tibial tubercle traction was applied in the conservative treatment, and closed reduction and internal fixationwere adopted after the failure of the conservative treatment. When the patient came to our hospital for the treatment of hip and knee joint pain for 20 years, the doctor discovered that the patient had severe genu recurvatum and avascular necrosis. We adopted staged treatment for the patients. First, the left hip artificial joint replacement was performed due to the femoral head necrosis. After the operation, the pain in the left hip disappeared. Three months later, the patient underwent the combination of tibial osteotomy and tibial tubercle transposition to treat genu recurvatum. One year after the operation, the anterior and lateral radiographs of the knee joint displayed that the osteotomy area healed well, without complications such as fracture nonunion and infection. The appearance of the knee joint returned to normal. According to UCLA Activity Score and WOMAC (The Western Ontario and McMaster Universities) Osteoarthritis Index, the patient's activity and function levels were assessed, and the postoperative scores were significantly improved compared with preoperative scores.Conclusion: Pediatric Femoral Neck Fractures should be treated promptly with surgery and long-term follow-ups. Total hip replacement is an effective method for the treatment of end-stage femoral head necrosis. Meanwhile, tibial traction should be avoided for children with lower extremity fractures, because it may damage the tibial growth plate, thus leading to the early closure of the metaphyseal region in children, and genu recurvatum. The modified surgery for the treatment of genu recurvatum is simple to operate and can avoid patella Baja, so it has a strong healing ability in the osteotomy area. The results of the surgery technique were ideal in this case.P.
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Affiliation(s)
- Fuyuan Deng
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Sichuan Provincial Laboratory of Orthopaedic Engineering, Luzhou, Sichuan, China
| | - Zhong Li
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Sichuan Provincial Laboratory of Orthopaedic Engineering, Luzhou, Sichuan, China
| | - Juncai Liu
- Department of Orthopaedics, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Sichuan Provincial Laboratory of Orthopaedic Engineering, Luzhou, Sichuan, China
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17
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Xin P, Tu Y, Hong Z, Yang F, Pang F, Wei Q, He W, Li Z. The clinical and radiographic characteristics of avascular necrosis after pediatric femoral neck fracture: a systematic review and retrospective study of 115 patients. J Orthop Surg Res 2020; 15:520. [PMID: 33176837 PMCID: PMC7661253 DOI: 10.1186/s13018-020-02037-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 10/28/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Avascular necrosis (AVN) after pediatric femoral neck fracture (PFNF) showed poor prognosis, but its clinical and radiographic characteristics remained unclear. METHODS A systematic review and a retrospective study were performed to evaluate the clinical and radiographic characteristics of patients with AVN after PFNF. RESULTS A total of 686 patients with PFNF and 203 patients with AVN from 21 articles were analyzed. Ratliff's classification was used in 178 patients, with types I, II, and III AVN accounting for 58.4%, 25.3%, and 16.3%, respectively. Ratliff's assessment was used in 147 patients, of whom 88.4% had an unsatisfactory prognosis. In retrospective study, 115 patients with a mean age of 13.6 ± 2.0 years were included. The mean interval between AVN and PFNF was 13.7 ± 9.5 months. At the time of diagnosis, 59.1% cases were symptomatic and 65.2% progressed to collapsed stage. Fifty (43.5%), 61 (53.0%), and 4 patients (3.5%) were defined as types I, II, and III , respectively, via Ratliff's classification. Thirteen (11.3%), 40 (34.8%), and 62 patients (53.9%) showed types A/B, C1, and C2 disease, respectively, via the JIC classification. Multivariate analysis demonstrated a strong relation between collapsed stage and symptomatic cases (OR = 6.25, 95% CI = 2.39-16.36) and JIC classification (OR = 3.41, 95% CI = 1.62-7.17). CONCLUSION AVN after PFNF showed a tendency toward extensive necrotic lesions, presumably resulting in a rapid progression of femoral head collapse. And the symptoms and the JIC classification are other two risk factors of collapse progression.
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Affiliation(s)
- Pengfei Xin
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, China.,Laboratory of Orthopaedics & Traumatology, Lingnan Medical Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yonggang Tu
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, China.,Department of Orthopaedics, Dongguan Eastern Central Hospital, Dongguan, Guangdong, China
| | - Zhinan Hong
- Department of Joint Surgery, The Third Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - Fan Yang
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, China.,Laboratory of Orthopaedics & Traumatology, Lingnan Medical Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Fengxiang Pang
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, China.,Laboratory of Orthopaedics & Traumatology, Lingnan Medical Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Qiushi Wei
- Department of Joint Surgery, The Third Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - Wei He
- Department of Joint Surgery, The Third Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.
| | - Ziqi Li
- The First Clinical Medical School, Guangzhou University of Chinese Medicine, Jichang Road 12#, District Baiyun, Guangzhou, Guangdong, China. .,Department of Joint Surgery, The Third Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.
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Current controversies in management of fracture neck femur in children: A review. J Clin Orthop Trauma 2020; 11:S799-S806. [PMID: 32999559 PMCID: PMC7503071 DOI: 10.1016/j.jcot.2020.05.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/24/2020] [Accepted: 05/25/2020] [Indexed: 11/21/2022] Open
Abstract
Paediatric femur neck fracture is an uncommon injury and is known for high rate of complications. This in turn, can have significant impact on development of hip and overall function of the child. Controversy prevails in many areas of management and it still remains a difficult injury to manage. Through this paper, an attempt has been made to summarize the current concepts in management and suggest current recommendations regarding the controversies so that these injuries can be managed judiciously. A systematic review was done as per PRISMA guidelines using pre-defined inclusion and exclusion criteria. 18 studies with better scientific evidence after quality assessment were included in the systematic review. Current trends and Controversial issues in management were then identified and discussed. It was observed that existing literature is inconclusive regarding several aspects of management of this injury with no clear guideline available. However, certain recommendations useful for decision making could be made. These injuries should be managed aggressively with operative fixation at the earliest and one should not hesitate to open reduce if acceptable alignment is not obtained after one or two gentle closed manipulations. Choice of implant and their configuration in neck can vary depending on age and weight of patient, type of injury and surgeon's preference. Initial fracture displacement could be considered to be most predictive for development of osteonecrosis of the femoral head, whereas, role of surgical decompression, type of fixation and timing of surgery is still debatable. Functional outcome is primarily affected by osteonecrosis of the femoral head, nonunion and severe coxa vara, whereas mild coxa vara, shortening, and premature closure of physis when considered alone, don't have significant influence on functional outcome in short term. Treatment of fracture neck femur in children is still controversial in many aspects and needs further research. It should be understood that complications can occur regardless of the method of treatment and might reveal their full impact many years after injury. Hence, a guarded prognosis should be explained to the parents and care-givers at the time of injury.
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Abstract
BACKGROUND Femoral neck fractures in children are rare injuries, occurring due to high-energy trauma. Due to the unique anatomy and blood supply of the proximal femur in growing children, these fractures are notorious for high rates of complications despite appropriate management. Classification of these fractures is according to the Delbet system, which not only guides management but also gives prognostic clues. Multiple fixation methods have been described and there is no consensus on what constitutes the best treatment. Osteonecrosis, non-union, coxa vara and premature physeal arrest are the most frequent complications. PURPOSE To review the current knowledge, discuss controversial aspects, and provide suggestions for future research. METHODS We have reviewed the literature on paediatric proximal femur fractures and have provided an evidence-based guide to the diagnosis and management of these injuries. Common complications have been elaborated and options for their prevention and/or management discussed. CONCLUSION There is universal agreement that anatomic reduction and stable internal fixation, supplemented by spica immobilization in younger children, are essential to obtain good outcomes. The role of capsular decompression, choice and configuration of implant, and appropriate timing of surgery are aspects that continue to be debated. Multicenter prospective studies are necessary to standardize treatment of these challenging injuries.
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20
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Fassihi SC, Mortman R, Shalkevich J, Lee D, Stoll WT, Thakkar S. Total Hip Arthroplasty for the Sequelae of Femoral Neck Fractures in the Pediatric Patient. Arthroplast Today 2020; 6:296-304. [PMID: 32509942 PMCID: PMC7264979 DOI: 10.1016/j.artd.2020.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 04/10/2020] [Accepted: 04/15/2020] [Indexed: 11/26/2022] Open
Abstract
Although rare, total hip arthroplasty (THA) may be indicated in pediatric patients with degenerative changes of the hip joint after previous trauma. To illustrate management principles in this patient population, this study describes the case of a 15-year-old female who sustained bilateral femoral neck fractures after a generalized tonic-clonic seizure, an atypical, low-energy mechanism for this injury. These fractures were not diagnosed until 14 weeks after the seizure episode, at which point they had progressed to nonunion on the left side, malunion on the right side, and degenerative hip joint changes were developing bilaterally. Bilateral THA was ultimately performed, and the patient had favorable outcomes at 1 year postoperatively. In determining the optimal management strategy for such patients, a multidisciplinary approach should be used, with input from the patient’s family, pediatrician, pediatric endocrinologist, pediatric orthopaedic surgeon, and adult reconstruction surgeon. From a surgical standpoint, this report highlights the importance of selecting the appropriate bearing surfaces, broaching technique, mode of implant fixation, and implant features when performing THA in the active pediatric patient.
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Affiliation(s)
- Safa C Fassihi
- Department of Orthopaedic Surgery, George Washington University, Washington, DC, USA
| | - Ryan Mortman
- Department of Orthopaedic Surgery, George Washington University, Washington, DC, USA
| | - Jacob Shalkevich
- Department of Orthopaedic Surgery, George Washington University, Washington, DC, USA
| | - Danny Lee
- Department of Orthopaedic Surgery, George Washington University, Washington, DC, USA
| | - William T Stoll
- Department of Orthopaedic Surgery, George Washington University, Washington, DC, USA
| | - Savyasachi Thakkar
- Department of Orthopaedic Surgery, Georgetown University MedStar Health, Washington, DC, USA
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21
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Sanghavi S, Patwardhan S, Shyam A, Nagda T, Naik P. Nonunion in Pediatric Femoral Neck Fractures. J Bone Joint Surg Am 2020; 102:1000-1010. [PMID: 32265357 DOI: 10.2106/jbjs.19.01117] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Sahil Sanghavi
- Sancheti Institute for Orthopaedics & Rehabilitation, Pune, India
| | | | - Ashok Shyam
- Sancheti Institute for Orthopaedics & Rehabilitation, Pune, India
| | - Taral Nagda
- SRCC NH Children's Hospital, Jupiter Hospital, and PD Hinduja National Hospital, Mumbai, India
| | - Premal Naik
- Smt. N.H.L. Municipal Medical College, Rainbow Superspeciality Hospital & Children's Orthopaedic Centre, Ahmedabad, India
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22
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Chen Y, Zhang X, Guo H, Liu N, Ren J, Lu C. Poor Outcomes of Children and Adolescents with Femoral Neck Fractures: A Meta-Analysis Based on Clinical Studies. Orthop Surg 2020; 12:639-644. [PMID: 32162445 PMCID: PMC7189036 DOI: 10.1111/os.12629] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 01/08/2020] [Accepted: 01/14/2020] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To comprehensively assess the differences in outcome between open reduction and closed reduction for children and adolescents with femoral neck fractures. METHODS Based on the predetermined strategies, eligible studies were obtained by searching Embase, the Cochrane Library, and PubMed databases (retrieval time: June 2018) and through manual retrieval for paper documents. The 95% confidence intervals (CI) and risk ratios (RR) were used as evaluation indexes. Moreover, the results of avascular necrosis, coxa vara, or non-union were compared between open reduction and closed reduction under random or fixed effects models. After sensitivity analysis was carried out, publication bias was evaluated for the eligible studies using Egger's test. RESULTS Six studies were included in our meta-analysis. No significant heterogeneity was found among the included studies (P ≥ 0.05) and, thus, the fixed effects model was used for merging the effect sizes of avascular necrosis (RR [95% CI] = 0.50 [0.26, 0.98], P = 0.04), coxa vara (RR [95% CI] = 0.16 [0.04, 0.70], P = 0.01), and non-union (RR [95% CI] = 0.22 [0.05, 0.93], P = 0.04). Sensitivity analysis suggested that the results of avascular necrosis were not stable (RR = 0.50, 95% CI = 0.25 1.17, P = 0.12), while those of coxa vara and non-union were stable. There was no significant publication bias among the eligible studies (t = -0.70, P = 0.522). CONCLUSION Femoral neck fractures treated by open reduction had less adverse outcomes compared with those treated by closed reduction.
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Affiliation(s)
- Yingpu Chen
- Department of OrthopedicsXi'an Hong Hui Hospital, Xi'an Jiaotong University Health Science CenterXi'anChina
| | - Xiaojun Zhang
- Department of OrthopedicsPeople's Hospital of TongchuanTongchuanChina
| | - Hao Guo
- Department of OrthopedicsXi'an Hong Hui Hospital, Xi'an Jiaotong University Health Science CenterXi'anChina
| | - Na Liu
- Department of OrthopedicsXi'an Hong Hui Hospital, Xi'an Jiaotong University Health Science CenterXi'anChina
| | - Jing Ren
- Department of OrthopedicsXi'an Hong Hui Hospital, Xi'an Jiaotong University Health Science CenterXi'anChina
| | - Chao Lu
- Department of OrthopedicsXi'an Hong Hui Hospital, Xi'an Jiaotong University Health Science CenterXi'anChina
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Yang H, Liu Y, Liu L. [Progress of hip fracture treatment in children]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:404-408. [PMID: 32174091 DOI: 10.7507/1002-1892.201907005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Objective To review the progress of hip fracture treatment in children. Methods Literature about the hip fracture treatment in children was extensively reviewed and summarized in terms of anatomy and blood supply, fracture classification, surgical treatment principles, and complications. Results The anatomical structure of children's hips and the characteristics of peripheral blood supply constantly change with age. Delbet classification is the most classic classification of hip fracture in children. Children's age and Delbet classification have significant effects on surgical treatment strategies and post-fracture complications. The timing of surgical treatment, accurate anatomical reduction, and appropriate internal fixation can effectively improve the prognosis and reduce the incidence of complications. Common complications include osteonecrosis of the femoral head, coxa vara, premature physeal closure, and nonunion. Conclusion There are still some controversies on the treatment concept and internal fixation choice for children's hip fracture. So it is necessary to further study the anatomy and blood supply characteristics of children's hip, improve the selection and application skills of internal fixation devices, so as to avoid serious complications.
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Affiliation(s)
- Hai Yang
- Department of Othopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Yang Liu
- Department of Othopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Lei Liu
- Department of Othopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
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Analysis of risk factors for complications after femoral neck fracture in pediatric patients. J Orthop Surg Res 2020; 15:58. [PMID: 32075662 PMCID: PMC7029480 DOI: 10.1186/s13018-020-01587-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 02/11/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pediatric femoral neck fracture is a rare injury but yields frequent complications. However, there is a paucity of data regarding the risk factors for these complications. PURPOSE The present article reports the rate of complications after femoral neck fracture in pediatric patients and investigates the possible risk factors. METHODS We retrospectively reviewed 44 children (mean age of 9.0 years, range from 2 to 14 years) who were surgically treated for femoral neck fracture in a single trauma center with a mean follow-up of 57.75 months (range from 11 to 224 months). Related clinical factors were recorded and analyzed by multivariable logistic regression. RESULTS Fracture displacement or Delbet-type fracture had no relation to the injury mechanism. However, younger children experienced severe trauma, combined injury, and low fracture location more than older individuals did. Children with combined injuries were more likely to have a longer waiting time for surgical reduction. Common complications included avascular necrosis (AVN) in 14 cases, nonunion of fracture in 2 cases, coxa vara in 4 cases, and premature physeal closure (PPC) in 7 cases. Only the Delbet type was an independent predictor of AVN (OR = 0.14, p = 0.030). Inadequate reduction was associated with higher rates of coxa vara (OR = 33.19, p = 0.032). Epiphysis penetration in children younger than 10 years old increased the rate of PPC (p = 0.032). No significant risk factor was found for fracture nonunion. CONCLUSION For femoral neck fracture in pediatric patients, both the injury mechanism and fracture characteristics have age-related distributions. Early reduction should be carried out as early as possible based on the safe condition of the child, but for younger children, transepiphyseal fixation should be avoided. AVN may be intrinsic to injury characteristics rather than resulting from the choice of treatment mode.
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Pan Y, Lu X, Lin R, Zhang X, Mei H, Guo Y, Chen S. Free Fracture Fragment Predicts Poorer Outcomes in Adolescents With Delbet II Femoral Neck Fracture. J Surg Res 2019; 248:14-19. [PMID: 31841732 DOI: 10.1016/j.jss.2019.10.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 08/09/2019] [Accepted: 10/05/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND This retrospective multicenter study investigated whether the presence of free fracture fragments is associated with the clinical outcome of adolescents with Delbet II femoral neck fracture (FNF). MATERIALS AND METHODS The study population comprised 74 adolescents with Delbet II FNF, with an average age of 13.31 y (range, 10-17 y). There were 19 and 55 patients, respectively, with and without (control) free fracture fragments. The patients underwent open (n = 41) or closed (n = 33) fracture reduction and then cannulated screw internal fixation. Postoperative functional evaluation was performed using Ratliff's criteria, and complications such as femoral head necrosis, premature epiphyseal closure, and coxa vara were recorded. RESULTS All patients achieved bony union during the mean follow-up period of 15.6 mo (range, 12-78 mo). By Ratliff's criteria, the clinical outcomes of the patients with free fracture fragment (three excellent, eight good, eight poor) were significantly worse compared with the control group (26 excellent, 20 good, and nine poor). The rate of complications (femoral head necrosis, premature epiphyseal closure, and coxa vara) of patients with free fracture fragments was significantly higher than that of the control patients. CONCLUSIONS In adolescents with Delbet II FNF, the presence of free fracture fragments is associated with poorer clinical outcomes. Delbet II FNF in adolescents with free fracture fragment may be a special clinical entity with a poorer outcome.
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Affiliation(s)
- Yuancheng Pan
- Department of Orthopedics, Fuzhou Second Hospital affiliated to Xiamen University, Fuzhou, China
| | - Xiaokun Lu
- Department of Orthopedics, Fuzhou Second Hospital affiliated to Xiamen University, Fuzhou, China
| | - Ran Lin
- Department of Orthopedics, Fuzhou Second Hospital affiliated to Xiamen University, Fuzhou, China
| | - Xinzhao Zhang
- Department of Orthopedics, Fuzhou Second Hospital affiliated to Xiamen University, Fuzhou, China
| | - Haibo Mei
- Department of Orthopedics, Hunan Children's Hospital, Changsha, China
| | - Yueming Guo
- Department of Orthopedics, Foshan Hospital of Traditional Chinese Medicine, Foshan, China
| | - Shunyou Chen
- Department of Orthopedics, Fuzhou Second Hospital affiliated to Xiamen University, Fuzhou, China.
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Abstract
Femoral neck fractures in children are rare injuries resulting from high-energy trauma. Different methods of treatment, lack of standard management protocols, and the high risk of complications make this injury one of the biggest challenges that an orthopaedic surgeon can face. This review focuses on the general aspects of the pediatric femoral neck fracture management as well as its complications and possible solutions.
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Initial displacement as a risk factor for avascular necrosis of the femoral head in pediatric femoral neck fractures: a review of one hundred eight cases. INTERNATIONAL ORTHOPAEDICS 2019; 44:129-139. [DOI: 10.1007/s00264-019-04429-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 10/01/2019] [Indexed: 10/25/2022]
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Wang WT, Li YQ, Guo YM, Li M, Mei HB, Shao JF, Xiong Z, Li J, Canavese F, Chen SY. Risk factors for the development of avascular necrosis after femoral neck fractures in children: a review of 239 cases. Bone Joint J 2019; 101-B:1160-1167. [PMID: 31474136 DOI: 10.1302/0301-620x.101b9.bjj-2019-0275.r1] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this study was to clarify the factors that predict the development of avascular necrosis (AVN) of the femoral head in children with a fracture of the femoral neck. PATIENTS AND METHODS We retrospectively reviewed 239 children with a mean age of 10.0 years (sd 3.9) who underwent surgical treatment for a femoral neck fracture. Risk factors were recorded, including age, sex, laterality, mechanism of injury, initial displacement, the type of fracture, the time to reduction, and the method and quality of reduction. AVN of the femoral head was assessed on radiographs. Logistic regression analysis was used to evaluate the independent risk factors for AVN. Chi-squared tests and Student's t-tests were used for subgroup analyses to determine the risk factors for AVN. RESULTS We found that age (p = 0.006) and initial displacement (p = 0.001) were significant independent risk factors. Receiver operating characteristic (ROC) curve analysis indicated that 12 years of age was the cut-off for increasing the rate of AVN. Severe initial displacement (p = 0.021) and poor quality of reduction (p = 0.022) significantly increased the rate of AVN in patients aged 12 years or greater, while in those aged less than 12 years, the rate of AVN significantly increased only with initial displacement (p = 0.048). A poor reduction significantly increased the rate of AVN in patients treated by closed reduction (p = 0.026); screw and plate fixation was preferable to cannulated screw or Kirschner wire (K-wire) fixation for decreasing the rate of AVN in patients treated by open reduction (p = 0.034). CONCLUSION The rate of AVN increases with age, especially in patients aged 12 years or greater, and with the severity of displacement. In patients treated by closed reduction, anatomical reduction helps to decrease the rate of AVN, while in those treated by open reduction, screw and plate fixation was preferable to fixation using cannulated screws or K-wires. Cite this article: Bone Joint J 2019;101-B:1160-1167.
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Affiliation(s)
- Wentao T Wang
- Pediatric Orthopedic Surgery Department, Fuzhou Second Hospital Affiliated to Xiamen University, Fuzhou, China
| | - Yiqiang Q Li
- Pediatric Orthopedic Surgery Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yueming M Guo
- Foshan Hospital of Traditional Chinese Medicine, Foshan, China
| | - Ming Li
- Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Haibo B Mei
- Department of Pediatric Orthopaedics, Hunan Children's Hospital, Changsha, China
| | - Jingfan F Shao
- Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Zhu Xiong
- Pediatric Orthopedic Surgery Department, Shenzhen Children's Hospital, Shenzhen, China
| | - Jin Li
- Wuhan Union Hospital, Wuhan, China
| | | | - Shunyou Y Chen
- Pediatric Orthopedic Surgery Department, Fuzhou Second Hospital Affiliated to Xiamen University, Fuzhou, China
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The Community Orthopaedic Surgeon Taking Trauma Call: Pediatric Femoral Neck Fracture Pearls and Pitfalls. J Orthop Trauma 2019; 33 Suppl 8:S22-S26. [PMID: 31290842 DOI: 10.1097/bot.0000000000001541] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Pediatric hip fractures are uncommon injuries but are associated with a high complication rate including avascular necrosis, coxa vara, nonunion, and premature physeal arrest. This is due in part to the unique anatomy of the proximal femur. Management principles are aimed at minimizing the risk of complications and emphasize the importance of early treatment with anatomic reduction and stable internal fixation with a low threshold for supplementing fixation with a spica cast. The age of the patient and Delbet fracture type dictate the optimal type of fixation for a given case. This article will offer evidence and experience-based tips intended to benefit on-call surgeons caring for these injuries.
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Papalia R, Torre G, Maffulli N, Denaro V. Hip fractures in children and adolescents. Br Med Bull 2019; 129:117-128. [PMID: 30753305 DOI: 10.1093/bmb/ldz004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 01/03/2019] [Accepted: 01/11/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Femoral neck fractures account for <1% of the fractures in children, and are produced by high energy trauma. The most commonly accepted treatment for such fractures is gentle manual anatomical reduction and internal fixation, yielding a healing rate between 80% and 90%. SOURCES OF DATA Electronic search through major web databases (Medline, Cochrane and Google Scholar). All types of article were eligible for inclusion, except for reviews, systematic reviews, meta-analyses and case reports. The methodological quality of the studies was assessed using the Methodological Index for NOn-Randomized Studies (MINORS). AREAS OF AGREEMENT Both open reduction and internal fixation (ORIF) and closed reduction and internal fixation (CRIF) can be used to manage hip fractures in paediatric patients. ORIF is more accurate in reducing and fixing the fracture, with better clinical and functional outcomes, and lower complication rate. Delayed fixation decreases the rate of acceptable outcome and increases the rate of complications. AREAS OF CONTROVERSY The methodological quality of the included studies is average-low, and the published evidence is not of sufficient quality to allow to draw final conclusion on the topic. GROWING POINTS Good results were reported for both ORIF and CRIF techniques, but are not supported by scientific evidence of adequate quality. More and better studies, including randomized trials, should be carried out to provide more scientifically evidence based conclusions.
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Affiliation(s)
- Rocco Papalia
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, Rome, Italy
| | - Guglielmo Torre
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, Rome, Italy
| | - Nicola Maffulli
- Faculty of Medicine, Surgery and Dentistry, Department of Musculoskeletal Disorders, University of Salerno, Baronissi, Salerno, Italy.,Queen Mary University of London, Barts and The London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London, England.,Institute of Science and Technology in Medicine, Department of Orthopaedics, Keele University School of Medicine, Stoke on Trent, England
| | - Vincenzo Denaro
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, Rome, Italy
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Abstract
In the pediatric population, femoral neck fracture is a relatively uncommon injury with a high complication rate, despite appropriate diagnosis and management. The anatomy and blood supply of the proximal femur in the skeletally immature patient differs from that in the adult patient. Generally, these fractures result from high-energy trauma and are categorized using the Delbet classification system. This system both guides management and aids the clinician in determining the risk of osteonecrosis after these fractures. Other complications include physeal arrest, coxa vara, and nonunion. Multiple fracture fixation methods have been used, with the overall goal being anatomic reduction with stable fixation. Insufficiency fractures of the femoral neck, although rare, must also be considered in the differential diagnosis for the pediatric patient presenting with atraumatic hip pain.
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AlKhatib N, Younis MH, Hegazy A, Ibrahim T. Early versus late treatment of paediatric femoral neck fractures: a systematic review and meta-analysis. INTERNATIONAL ORTHOPAEDICS 2018; 43:677-685. [PMID: 29869695 DOI: 10.1007/s00264-018-3998-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 05/18/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE Femoral neck fractures in children represent less than 1% of all paediatric fractures. Osteonecrosis of the femoral head is one of the devastating complications of this fracture. Time to treatment is one of the most important predictors of this outcome with no clear consensus in the literature. The aim of this study was to determine whether early treatment (< 24 hours) of pediatric femoral neck fractures is associated with a lower rate of osteonecrosis of the femoral head compared to late treatment (> 24 hours). METHODS We searched several databases (PubMed, Embase, and Cochrane library), from January 1966 to November 2017 for any comparative studies that evaluated early (< 24 hours) versus late (> 24 hours) treatment of paediatric femoral neck fractures. We pooled the effect sizes using fixed effects model that compared the rate of osteonecrosis of the femoral head between children undergoing early versus late treatment, open versus closed reduction, displaced versus non-displaced and different Delbet type femoral neck fractures. Descriptive and qualitative data was also extracted. RESULTS Of the 391 articles identified, six studies (prospective and retrospective cohort studies) were eligible for the meta-analysis, with a total of 231 paediatric femoral neck fractures. The pooled odds ratio (OR) for osteonecrosis of the femoral head did not show any statistically significant difference between early (< 24 hours) versus late (> 24 hours) treatment (OR = 1.19, 95% CI 0.56, 2.51, I2 = 23.6%), nor between open versus closed reduction of paediatric femoral neck fractures (OR = 1.62, 95% CI 0.82, 3.22, I2 = 19.57%). Displaced and Delbet type I/II femoral neck fractures were 3.8 (OR = 3.81, 95% CI 1.49, 9.78, I2 = 0.00%) and 2.4 (OR = 2.43, 95% CI 1.28, 4.61, I2 = 0.57%) times more associated with osteonecrosis of the femoral head compared to non-displaced and Delbet type III/IV fractures respectively. CONCLUSIONS The cumulative evidence at present does not indicate an association between the time to treatment or method of reduction of femoral neck fractures in children and the risk of osteonecrosis of the femoral head. However, initial expedient treatment of femoral neck fractures in children should always remain the rule especially for displaced and Delbet type I/II femoral neck fractures. LEVEL OF EVIDENCE II/III.
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Affiliation(s)
- Nedal AlKhatib
- Department of Surgery, Section of Orthopedics, Hamad General Hospital, Doha, Qatar
| | - Manaf H Younis
- Department of Surgery, Section of Orthopedics, Hamad General Hospital, Doha, Qatar
| | - Abdelsalam Hegazy
- Department of Surgery, Section of Orthopedic Surgery, Sidra Medical & Research Center, PO Box 26999, Doha, Qatar
| | - Talal Ibrahim
- Department of Surgery, Section of Orthopedics, Hamad General Hospital, Doha, Qatar.
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33
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Abstract
Pediatric proximal femur fractures are rare injuries resulting from high-energy trauma. The Delbet classification is used when describing these injuries, and associates fracture type to the development of avascular necrosis. Historically, casting was utilized in the treatment of these injuries, but high complication rates following this approach have changed the treatment modality to early and anatomic fixation. Complications associated with these injuries including avascular necrosis, non-union, coxa-vara, and premature physeal fusion. Achieving anatomic reduction and performing internal fixation within 24 h from time of injury has become the standard of care in the treatment of pediatric proximal femur fractures.
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Affiliation(s)
- Brian L Dial
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Robert K Lark
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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Yaokreh JB, Odehouri-Koudou TH, Dieth GA, Tembely S, Kouame YGS, Kouame BD, Ouattara O. Management of femoral neck fractures in children: Experience of a short series in a developing country. Afr J Paediatr Surg 2018; 15:114-117. [PMID: 31290477 PMCID: PMC6615012 DOI: 10.4103/ajps.ajps_93_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Fractures of the femoral neck are rare injuries in children but can have many devastating complications. Their treatment is not standardized, but the objectives are early anatomic reduction to minimize the risk for complications. The aim of this study was to assess outcomes of a short series of femoral neck fractures managed in a resource-limited setting. MATERIALS AND METHODS The medical charts of 11 children who were managed in our institution for femoral neck fractures between January 2000 and December 2015 were assessed retrospectively. There were two cases (n = 2) of Delbet type I, 5 (n = 5) type II, and 4 (n = 4) type III fractures. Patients were treated either surgically by open reduction and internal fixation (n = 4) or conservatively by traction followed by spica cast (n = 7). Outcomes were assessed using Ratliff system. RESULTS Femoral neck fracture incidence was one case per year. Of the 11 patients, there were 7 boys and 4 girls, with a mean age 9.4 ± 3.28 years. At the mean follow-up of 3.64 ± 1.97 years (range, 2-8.8 years), outcome was fair to good in 8 (72.7%) and poor in 3 (27.3%) cases. Average union time was 13.5 ± 1.77 weeks. Complication rate was 72.7%. Avascular necrosis occurred in three cases (27.3%). Six patients (54.5%) developed coxa vara, with a mean neck-shaft angle of 102.16° ±12.07° (range, 90°-118°). Five patients (45.5%) had leg length discrepancy with a mean 18 mm (range, 7-35 mm). DISCUSSION local conditions negatively influenced the management of femoral neck fractures. Conservative treatment led to many complications which increase the cost of management.
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Affiliation(s)
- Jean Baptiste Yaokreh
- Department of Mother and Children, University of Félix Houphouet Boigny Pediatric Surgery Unit, CHU Yopougon, Côte d'Ivoire, Abidjan, Côte d'Ivoire
| | - Thierry-Herve Odehouri-Koudou
- Department of Mother and Children, University of Félix Houphouet Boigny Pediatric Surgery Unit, CHU Yopougon, Côte d'Ivoire, Abidjan, Côte d'Ivoire
| | - Gaudens Atafy Dieth
- Department of Mother and Children, University of Félix Houphouet Boigny Pediatric Surgery Unit, CHU Yopougon, Côte d'Ivoire, Abidjan, Côte d'Ivoire
| | - Samba Tembely
- Department of Mother and Children, University of Félix Houphouet Boigny Pediatric Surgery Unit, CHU Yopougon, Côte d'Ivoire, Abidjan, Côte d'Ivoire
| | - Yapo Guy-Serge Kouame
- Department of Mother and Children, University of Félix Houphouet Boigny Pediatric Surgery Unit, CHU Yopougon, Côte d'Ivoire, Abidjan, Côte d'Ivoire
| | - Bertin Dibi Kouame
- Department of Mother and Children, University of Félix Houphouet Boigny Pediatric Surgery Unit, CHU Yopougon, Côte d'Ivoire, Abidjan, Côte d'Ivoire
| | - Ossenou Ouattara
- Department of Mother and Children, University of Félix Houphouet Boigny Pediatric Surgery Unit, CHU Yopougon, Côte d'Ivoire, Abidjan, Côte d'Ivoire
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Issın A, Çamurcu İY, Konya MN, Şahin V. Pediatrik Femur Boyun Kırıklarının Klinik ve Radyolojik Sonuçları. ACTA MEDICA ALANYA 2017. [DOI: 10.30565/medalanya.320251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Palencia J, Alfayez S, Serro F, Alqahtani J, Alharbi H, Alhinai H. A case report of the management and the outcome of a complete epiphyseal separation and dislocation with left anterior column fracture of the acetabulum. Int J Surg Case Rep 2016; 23:173-6. [PMID: 27161547 PMCID: PMC5022068 DOI: 10.1016/j.ijscr.2016.04.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 03/16/2016] [Accepted: 04/24/2016] [Indexed: 11/30/2022] Open
Abstract
A case of a child with hip dislocation and acetabular fracture is presented. The patient underwent reduction and internal fixation with two cannulated screws. Osteonecrosis of the femoral head was evident after six months.
Introduction Femoral head and neck fractures in children are uncommon, accounting for fewer than 1% of all pediatric fractures and fewer than 8% of all hip fractures. Furthermore, traumatic transphyseal hip fracture is rare to present in daily practice especially when associated with an acetabular fracture. Presentation of the case A twelve years old boy, not known to have any chronic illnesses, presented to the emergency department as a case of polytrauma after a road traffic accident. Signs of left hip dislocation were discovered upon physical examination. X-rays and CT scans, revealed a complete transphyseal posterior dislocation and a left anterior column fracture of the acetabulum with a minimal displacement. Within five hours, the patient underwent open reduction and internal fixation by two cannulated screws. The acetabular fracture was managed conservatively. After six months, there were clear signs of osteonecrosis of the femoral head. Discussion A high-energy trauma in children and adolescents can lead to simultaneous epiphyseal and acetabular fractures which are associated with a poor prognosis. The age seems to play a role as patients older than ten years have a higher risk of developing AVN after sustaining a hip dislocation regardless of the time of intervention. Conclusion Epiphyseal fracture with dislocation of the femoral head is rare among children and adolescents, especially when associated with an acetabular fracture. AVN in such cases can develop, and it represents a challenge to orthopedic surgeons due to the poor prognosis and the future functional limitations of the joint.
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Affiliation(s)
| | | | - Firas Serro
- King Saud Medical City, Riyadh, Saudi Arabia.
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