Outcomes of elderly patients with nondisplaced or minimally displaced femoral neck fractures treated with internal fixation: A systematic review and meta-analysis

BACKGROUND

Internal fixation remains the treatment of choice for non-displaced femoral neck fractures in elderly patients. Improved outcomes with arthroplasty following displaced femoral neck fractures may indicate that outcomes of non-displaced patterns should be reexamined. The aim of our study was to conduct a systematic review of the orthopaedic literature to determine the outcomes of internal fixation for the treatment of non-displaced and minimally displaced femoral neck fractures in elderly patients.

METHODS

Relevant articles were identified using PubMed, Embase, and CENTRAL databases. Manuscripts were included if they contained (1) patients 60 years or older with (2) nondisplaced or minimally displaced (Garden I or II) femoral neck fractures (3) treated with internal fixation (4) separately reported outcomes in this patient population. The primary outcome was reoperation. Secondary outcomes included mortality, patient-reported outcomes, length of hospitalization, infection, and transfusions. Fixed and random effects modeling was used to determine pooled estimates of the outcomes.

RESULTS

Twenty-seven studies were identified with a total of 21,155 patients, all of which were treated with internal fixation. The pooled risk of reoperation was 14.1% (95% CI: 10.6-18.2). The risk of one-year mortality was 14.6% (95% CI: 11.5-18.2) based on the reporting in 15 studies.

CONCLUSIONS

The risk of reoperation and mortality following the treatment of nondisplaced femoral neck fractures in the elderly with internal fixation exceeds 14%. This complication profile may be unacceptably high. Arthroplasty may offer improved short-term functional outcomes and a reduced risk of reoperation. However, there is currently little evidence to consider this treatment to be an alternative to internal fixation.

Management of young femoral neck fractures: is there a consensus?

BACKGROUND

Femoral neck fractures in young adults (ages <60) are high-energy injuries that are associated with major fracture healing complications such as avascular necrosis, nonunion, and significant shortening. Historically, evidence from small trials has suggested multiple cannulated screws were the optimal implant; however, newer studies and implant designs warrant reevaluation of screws as the gold standard among surgeons. In addition, controversies surrounding reduction technique and urgency of surgical fixation have been previously identified. We aimed to survey surgeon treatment preferences for these challenging fractures.

METHODS

A 17-item survey was developed and tested for validity and reliability prior to administration. The questionnaire characterised surgeon demographics, treatment preferences for displaced and undisplaced fractures, and controversies for future clinical trials. The target population consisted of surgeons from the Canadian Orthopaedic Association, the Orthopaedic Trauma Association, and attendees at an international fracture course.

RESULTS

540 surgeons completed the survey, exceeding our sample size requirement. There was a similar proportion of respondents from academic and community hospitals. Most surgeons (61%) treat 1-5 young adult femoral neck fractures per year. For undisplaced fractures, 78% of respondents prefer to use multiple cannulated screws. For displaced fractures, equal preference for multiple screws (46%) and the sliding hip screw (SHS, 49%) was reported. The majority of surgeons perform an open reduction in less than 25% of cases, and the time to fixation was typically between 8 and 24h.

CONCLUSIONS

Multiple cannulated screws remain the preferred treatment for most surgeons treating undisplaced fractures; however, there is an equal divide in preference between multiple screws and the SHS for displaced fractures. This increased preference for the SHS contradicts previous survey and small trial data recommending multiple screws for all fracture patterns. The lack of surgeon consensus and the high rates of fracture complications associated with fixation of young femoral neck fractures supports the need for definitive clinical trials to optimise patient important outcomes.

Complications following young femoral neck fractures

BACKGROUND

Femoral neck fractures in patients 60 years of age or younger are challenging injuries to treat because of the high-energy trauma mechanisms and the displaced fracture patterns typically found in this patient population. Understanding the burden of disease is an important first step in addressing treatment controversies in this population. The purpose of the current study is to quantitatively pool the incidence of patient important complications following internal fixation of young femoral neck fractures.

METHODS

A comprehensive search of the Medline, Embase, CINAHL, Cochrane Database of Systematic Reviews, and Central databases was completed under the direction of a biomedical librarian. Multiple outcomes of interest (complications) were collected and included: reoperation, femoral head avascular necrosis, fracture non-union, infection, implant failure, and malunion.

RESULTS

1558 fractures from 41 studies were included in the meta-analysis. An18.0% pooled reoperation incidence was observed for isolated femoral neck fractures. The total pooled incidence of avascular necrosis (AVN) was 14.3%, and the total incidence of nonunion was 9.3%. When stratified for fracture displacement displaced fractures were more likely to undergo reoperation and to result in AVN or non-union. The total incidence of malunion was 7.1%, implant failure was 9.7%, and surgical site infection was 5.1%. Complications associated with a femoral neck fracture treated in conjunction with an ipsilateral femoral shaft fracture were lower overall than the pooled estimates for isolated neck fractures.

CONCLUSIONS

The results of our analysis demonstrate that the incidence of complications experienced by young femoral neck fracture patients is relatively high. Reoperation following internal fixation of isolated femoral neck fractures occurred in nearly 20% of cases, and AVN and nonunion were the most common complications that likely contributed to repeat surgeries. These results highlight the importance of further efforts to improve the clinical outcomes in this population.

Psychometric analysis of measuring functional outcomes in tibial plateau fractures using the Short Form 36 (SF-36), Short Musculoskeletal Function Assessment (SMFA) and the Western Ontario McMaster Osteoarthritis (WOMAC) questionnaires

Patients participating in a modern prospective orthopaedic trauma database may be asked to complete many functional outcome measures, adding to the burden of study participation. This prospective study assessed the utility and responsiveness of the generic Short Form 36 (SF-36) and the disease specific Short Musculoskeletal Function Assessment (SMFA) and the Western Ontario McMaster Osteoarthritis (WOMAC) questionnaires in 55 patients treated operatively for tibial plateau fractures with the goal of determining if there was clear benefit of using multiple measures in a lower extremity peri-articular fracture population. There was very good correlation between all three scores at 6 and 12 months, indicating they are measuring similar factors. Responsiveness was assessed using the standard response mean (SRM), proportion of patients attaining the minimal clinically important difference (MCID) between 6 and 12 months, and floor and ceiling effects. The SRM for the SF-36 was statistically higher than the SRM for the SMFA or the WOMAC. Significantly more patients were found to have a MCID between 6 and 12 months post-surgery based on the SF-36 than the other two functional scores. There was no floor effect found on any of the 3 functional scores evaluated; however, a significant ceiling effect was noted with the WOMAC but not with the SF-36 or the SMFA. These results, along with the usefulness of the SF-36 for comparing disease burden across populations, favour the SF-36 as the instrument of choice in assessing functional outcome in patients with tibial plateau fractures.

Reporting and interpretation of the functional outcomes after the surgical treatment of disruptions of the pelvic ring

We performed a systematic review of the literature to evaluate the use and interpretation of generic and disease-specific functional outcome instruments in the reporting of outcome after the surgical treatment of disruptions of the pelvic ring. A total of 28 papers met our inclusion criteria, with eight reporting only generic outcome instruments, 13 reporting only pelvis-specific outcome instruments, and six reporting both. The Short-Form 36 (SF-36) was by far the most commonly used generic outcome instrument, used in 12 papers, with widely variable reporting of scores. The pelvis-specific outcome instruments were used in 19 studies; the Majeed score in ten, Iowa pelvic score in six, Hannover pelvic score in two and the Orlando pelvic score in one. Four sets of authors, all testing construct validity based on correlation with the SF-36, performed psychometric testing of three pelvis-specific instruments (Majeed, IPS and Orlando scores). No testing of responsiveness, content validity, criterion validity, internal consistency or reproducibility was performed.

The existing literature in this area is inadequate to inform surgeons or patients in a meaningful way about the functional outcomes of these fractures after fixation.

Measuring shoulder injury function: common scales and checklists

The increasing shift towards patient-centred healthcare has lead to an emergence of patient-reported outcome instruments to quantify functional outcomes in orthopaedic patients. Unfortunately, selecting an instrument for use in a shoulder trauma population is often problematic because most shoulder instruments were initially designed for use with chronic shoulder pathology patients. To ensure an instrument is valid, reliable, and sensitive to clinical changes, it is important to obtain psychometric evidence of its use in the target population. Four commonly used shoulder outcome instruments are reviewed in this paper: American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES); Constant-Murley shoulder score (CMS); Disabilities of Arm, Shoulder, and Hand (DASH); Oxford Shoulder Score (OSS). Each instrument was reviewed for floor or ceiling effects, validity, reliability, responsiveness, and interpretability. Additionally, evidence of each instrument's psychometric properties was sought in shoulder fracture populations. Based on the current literature, each instrument has limited amounts of evidence to support their use in shoulder trauma populations. Overall, psychometric evaluations in isolated shoulder fracture populations remain scarce, and clinicians must remember that an instrument's properties are defined for the population tested and not the instrument. Therefore, caution must always be exercised when using an instrument that has not been fully evaluated in trauma populations.

Ureteropelvic junction disruption and distal ureter injury associated with a Chance fracture following a traffic accident: a case report

A 10-year-old girl sustained a ureteropelvic junction disruption and distal ureter injury associated with the Chance fracture following a traffic accident. She was sitting on the rear seat of a car wearing a lap belt. Extensive small bowel mesenteric trauma was noted. Radiography revealed a left haemothorax with mediastinal shift and an unstable flexion-distraction vertebral fracture at L2 (Chance fracture). Subsequent intravenous pyelography demonstrated proximal extravasation from the right kidney without continuity to the upper and mid ureter, indicating a ureteropelvic junction avulsion or necrosis. Definitive surgery was delayed until day 33 because of urosepsis. Due to extensive small bowel resection, ischaemia of the ureter, and the history of urosepsis, a right subcapsular nephrectomy (rather than ureteral reconstruction) was considered the safest option for minimising further complications. It is important that trauma specialists recognise additional injuries after major trauma. Early use of a multidisciplinary approach is recommended to reduce morbidity and mortality.

Comminuted simultaneous bilateral tibial tubercle avulsion fractures: a case report

A 16-year-old male had simultaneous bilateral tibial tubercle avulsion fractures after making a sudden stop while running at full speed. The left knee injury (type V) was minimally displaced, was treated conservatively with closed reduction, and the patient recovered uneventfully. The right tibial tubercle injury was unusual. The tuberosity and anterior aspect of the proximal epiphysis remained as one, but there was severe intra-articular comminution posterior to the displaced tubercle fragment. The right knee injury (type III) required open reduction and internal fixation to reduce the apophyseal fragment and 2 intra-articular displaced fragments. The patient's recovery was complicated by a severe, persistent flexion deformity on the right side. Eventually, the patient required manipulation under anaesthesia, extensive continuous passive mobilisation and a turnbuckle extension splint. A residual 5-degree flexion deformity remained at 16 months post-injury. This case highlights the importance of identifying any intra-articular fragments, their careful anatomical reduction, and aggressive mobilisation when treating tibial tubercle avulsion fractures.