[ANATOMO-CLINICAL FORMS OF FEMORAL NECK FRACTURES].
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Femoral Neck Fractures↗
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Cortical screw support in femoral neck fractures. A radiographic analysis of 87 fractures with a new mensuration technique.
In 87 femoral neck fractures, operated on with 2 von Bahr screws and followed for up to 2 years, the positions of the fixating screws were determined with a new mensuration technique which compensates for the variations in hip rotation in routine radiographs. The union rate of the fractures was related to the position of the screws. A posterior placement of the proximal screw and an inferior placement of the distal screw in both the femoral head and neck improved the outcome substantially.
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[Geriatric femoral neck fractures--how to regain prefracture ambulatory status].
The incidence of hip fractures increases with increasing age. And mortality rate in elderly patients of hip fractures are high and which is reported to be up to 30% within 1 year following fractures. Prosthetic replacements for femoral neck fractures and internal fixations using solid fixation devices for intertrochanteric fractures are recommended for these elderly patients for regaining preinjury level of ambulation and good and reasonable quality of their lives.
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Bone grafting in femoral neck fractures: results in 28 cases operated on with multiple pinning and cancellous bone grafting.
Twenty-eight patients with displaced femoral neck fractures were operated on with multiple pinning combined with cancellous bone grafting from the ipsilateral greater trochanter. The bone graft was introduced through a drilled channel in the femoral neck without exposing the fracture. At follow-up after 2 years, seven patients had died. Two patients had been reoperated with prosthetic replacement of the hip. Nineteen fractures were united and one had developed segmental collapse. In femoral neck fractures, complications from non-union and segmental collapse are still a major problem. Even if the impaired vascular supply to the femoral head is responsible for most of the complications, anatomic reduction and a stable fixation are conductive to fracture union. Comminution of the posterior wall of the femoral neck has a negative influence on the security of fixation due to a persisting posterior gap after reduction. In previous reports, bone grafting of the posterior defect in the femoral neck through an open approach has achieved good results. Only a few studies, however, describe a technique of introducing bone chips through a drilled channel in the femoral neck. The use of the ipsilateral greater trochanter as the sole donor site for bone grafting in femoral neck fractures has not been reported previously.
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[Relationships between hemostatic variables and delay of surgical repair of femoral neck fracture in elderly patients].
BACKGROUND: This study was conducted to clarify the preoperative risk of thrombosis in elderly patients with femoral neck fracture by determining the relationships between hemostatic variables and time from injury until surgical repair. METHODS: Thirty-four patients over 70 years of age with femoral neck fracture were assigned to the following three groups according to the delay of surgical repair: usual operation group (within 3 days), delayed operation group (from 4 to 7 days) and much delayed operation group (more than 8 days). Hemostatic variables including molecular markers were determined before surgical repair. RESULTS: Thrombin antithrombin complex level in the usual operation group was significantly increased. The D-dimer level in the usual operation group was significantly higher than that in the delayed operation group, but the levels in the delayed and much delayed operation groups were still higher than the levels in normal subjects. CONCLUSIONS: These findings suggest that elderly patients with femoral neck fracture may have a relatively high risk for the occurrence of pulmonary thromboembolism receiving anesthesia for surgical repair because of hypercoagulopathy caused by stress response and possible deep vein thrombosis caused by lying on a bed for a long period.
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Thompson hemiarthroplasty is superior to Ullevaal screws in treating displaced femoral neck fractures in patients over 75 years. A prospective randomized study with two-year follow-up.
BACKGROUND AND AIMS: The Finnish orthopaedic tradition has preferred hemiarthroplasty to internal fixation in femoral neck fracture treatment, while in Sweden internal fixation has been the method of choice. We decided to study whether internal fixation would prove superior to hemiarthroplasty even in displaced femoral neck fractures in patients over 75 years old. MATERIAL AND METHODS: We randomized 32 displaced femoral neck fractures in patients over 75 years old to receive internal fixation or hemiarthroplasty. RESULTS: Fifteen (47%) patients died within two years. Seven of 16 (44%) patients in the internal fixation group were reoperated, none in the hemiarthroplasty group (p = 0.007). Seven of the complications in the internal fixation group developed during the first year and it would have been unethical to continue the study. CONCLUSIONS: We conclude that displaced femoral neck fractures in patients over 75 years should be treated by arthroplasty.
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Vitamin D status and concentrations of serum vitamin D metabolites and osteocalcin in elderly patients with femoral neck fracture: a follow-up study.
Vitamin D status and the serum osteocalcin concentration in patients with femoral neck fractures were studied as follows. Thirty-seven elderly patients (P) with fracture of the femoral neck were studied, whereas 24 age-matched persons (C) seen at the out-patient department for non-orthopaedic reasons served as controls. The dietary intake of vitamin D, estimated using a vitamin D score based on food items known to be the main sources of vitamin D, was significantly lower in the patients than in the controls. There was no difference in the serum 25-hydroxy-vitamin D (25-OH-D) (P: 22.3 +/- 7.5 nmol/l; C: 27.5 +/- 13.5) or the serum 1,25-dihydroxy-vitamin D3 concentration (P: 86 +/- 43 pmol/l; 31) C: 85 +/- 31) between the groups. The 25-OH-D concentration was, however, low as compared to reference values, suggesting vitamin D deficiency in both groups. There was no difference in the serum osteocalcin concentration between the groups (P: 3.1 +/- 1.7 micrograms/l; C: 3.4 +/- 1.5). One year later the serum osteocalcin concentrations (5.9 +/- 2.2 micrograms/l, n = 11) was significantly higher (P less than 0.005) in the patients than at the time of the fracture (3.2 +/- 2.2 micrograms/l), indicating an active bone turnover in the patients still present 1 year after the fracture.
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Torsion and bending analysis of internal fixation techniques for femoral neck fractures: the role of implant design and bone density.
To evaluate pin/screw/plate fixation for management of femoral neck fractures, 39 proximal femora were tested in both torsion and flexion under physiological loading conditions. Three, four, or five implants of six commonly used multiple-fixation devices, and a sliding hip screw with and without an additional 6.5-mm cancellous screw were examined in paired femora. The intact and postfixation femora were initially subjected to a single applied moment, and the torsion and bending stiffness were determined from the load-deformation data. Postfixation femora were also subjected to cyclic loading in flexion at three load ranges, and fixation was judged successful if no failure occurred on or before 1,500 cycles of 667 to 2,000 N of a combined compressive force and moment. Anterior-posterior and lateral radiographs of each specimen were taken after fixation in order to evaluate Singh's index of bone density, fracture reduction, implant placement, and cross-sectional diameter of the femoral neck. Bone density was also evaluated by computed tomography (CT) and physical measurement of core samples obtained from the femoral head. The results indicate that there appears to be no justification for the use of more than three pin/screw implants for management of femoral neck fractures. Bone density was found to correlate with fracture stability and may be a useful predictor of fixation success.
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[The lag screw fixation of medial femoral neck fractures (author's transl)].
The lag screw osteosynthesis of medial femoral neck fractures is a straightforward procedure with little danger of complications. A conclusion may be drawn from the results of several authors that this method may even have a favourable influence in reducing the frequency of pseudarthrosis. In order to come to a final conclusion, however, the results of large treatment programmes would have to be studied. Fractures which are technically accurately treated allow probably full weight bearing. Lag screw osteosynthesis using more than 2 spongiosa screws in a parallel position has proved, both theoretically and practically, to be a useful method of treatment. The caudal screws increase the stability due to their position on the caudal rim of the femoral neck, while the cranial screws ensure against rotation and exertion of tensile force.
Biomechanical Phenomena↗
Biomechanics of pin and screw fixation of femoral neck fractures.
Using an in vitro cadaveric femoral neck osteotomy model and a paired experimental design, we compared fixation stiffness and yield load for three- and four-pin configurations for both Knowles pins and Asnis screws and for three Asnis screws versus an AO-ASIF sliding hip screw. Repeat measure analyses of variance indicated a significant increase in stiffness (p < 0.05) with the use of three versus four pins; the yield load did not depend significantly on the number of pins. Fixation was significantly stiffer (p < 0.01) and stronger (p = 0.02) for Knowles pins if the osteotomy was oblique rather than transverse to the femoral neck; the opposite was found for Asnis screws. Femoral fixed with hip screws were significantly stiffer (p < 0.01) than the contralateral side fixed with three Asnis screws. No significant difference in yield load was observed, however. Clinically, it appears from these findings that the use of three Asnis screws or three Knowles pins provides modest increases (averaging 4%) in fixation stiffness with no degradation in strength when compared with four screws or pins. Parallel placement of Asnis screws also provides advantages over nonparallel Knowles pins by allowing controlled impaction of the femoral head. While three Asnis screws provide fixation stiffness approximately 40% less than that found with a sliding hip screw, there is no compromise in fixation strength.
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In-hospital mortality after femoral neck fracture: do internal fixation and hemiarthroplasty differ?
In this article, we examine rates of in-hospital mortality of elderly patients with femoral neck fracture treated with internal fixation or hemiarthroplasty. Data were analyzed for 51,003 patients (> or = 65 years old) admitted with femoral neck fractures to New York state hospitals between 1985 and 1996. The primary outcome examined was in-hospital mortality. Associations between type of surgical procedure and outcome were assessed using a multiple logistic regression model, adjusting for patient age, sex, race, number of comorbidities, and residence in a nursing facility before hip fracture. Approximately 30% of the study group had undergone open or closed reduction and internal fixation; the other 70% had undergone hemiarthroplasty. Forty-six percent of the internal fixation group and 56% of the hemiarthroplasty group were 85 years old or older (P < .001). Median hospital stays were 13 days for the internal fixation group and 15 days for the hemiarthroplasty group (P < 001). In-hospital mortality was 5.1% overall, 3.9% for the internal fixation group, and 5.6% for the hemiarthroplasty group (P < .001). The association between type of procedure and mortality held after adjusting for patient age, sex, and number of comorbidities (odds ratio, 1.42; 95% confidence interval, 1.29-1.56; P < .001). After controlling for potential confounding variables, we found that elderly patients who had undergone hemiarthroplasty after femoral neck fracture were more likely to die during hospitalization than those who had undergone internal fixation.
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[Comparison of primary arthroplasty with early salvage arthroplasty after failed internal fixation for displaced femoral neck fractures in elderly patients].
OBJECTIVES: We compared the results of primary total hip arthroplasty (THA) with those of early salvage THA following failure of internal fixation for acute displaced femoral neck fractures in elderly patients. METHODS: Patients with displaced femoral neck fractures (Garden type III, IV) were treated with either early salvage arthroplasty following failure of internal fixation (n=34; mean age 68 years) or THA (n=34; mean age 67.5 years). Both groups consisted of 8 men and 26 women with the same age range (60 to 75 years). Uncemented THA was performed in both groups. All patients were physiologically and socially active before the initial trauma. The hips were evaluated with the use of the Merle D'Aubigne scoring system. Prognostic risk factors were determined on radiographs obtained before or shortly after internal fixation. The mean follow-up was 5.2 years in the secondary and 5 years in the primary THA groups. RESULTS: During the first year of THA, there were 21 complications in 16 patients and nine complications in six patients in the secondary and primary THA groups, respectively (p<0.05). The results with respect to pain were worse and reoperation rate was higher in the revision group (p<0.05). The mean Merle D'Aubigne hip scores for pain, mobility, and walking were higher in the primary THA group. Radiographs taken before or after internal fixation showed prognostic risk factors in 32 patients (94.1%). CONCLUSION: Primary THA is a good choice of treatment for femoral neck fractures in physiologically and socially active elderly patients with a high life expectancy and cognition level.
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Factors influencing postoperative movement in displaced femoral neck fractures: evaluation by conventional radiography and stereoradiography.
Postoperative movement in 46 displaced femoral neck fractures was studied using roentgen stereophotogrammetric analysis (RSA). Thirty-four fractures became stable, all within 1 year. Measurements on pre- and postreduction radiographs and scintimetry were performed to evaluate factors of importance in healing, redisplacement, and nonunion. Thirty-three fractures were treated with two hook-pins with (7 cases) or without (26 cases) a plate, and 13 were treated with two cancellous screws. Presence of intermediate fracture fragments and fixation with two screws implied increased movement of the femoral head center during the postoperative period. Remaining ad latus displacement on the anteroposterior or lateral view after reduction of more than 1 mm and low scintimetric uptake implied increased risk of redisplacement or pseudarthrosis. Increased displacement of the femoral head center during the first postoperative month was recorded in fractures that did not heal. The magnitude of the femoral head rotations did not differ between the implants, but smaller screw axis rotations were noted in fractures that subsequently healed. In most hips fixated with screws, the instant center of femoral head rotation went through the femoral head or neck, whereas hook-pin fixation more commonly was associated with screw axis position within or close to the trochanteric region, suggesting a more durable fixation in the femoral head of this device.
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Osteon morphometry in females with femoral neck fractures.
The authors measured osteon dimensions and number in specimens of cortical bone obtained from the medial femoral neck (calcar) from nine female patients treated with hemiarthroplasty for femoral neck fractures, and from 12 (seven women, five men) age-matched cadavers without fractures. Specimens from the same location in 14 (seven women, seven men) younger patients treated with total hip arthroplasty (THA) for osteoarthrosis were also studied. There were fewer osteons per unit area and the osteons and their Haversian canals were bigger in the fracture group than in the nonfracture or osteoarthritic groups. Patients with femoral neck fractures also exhibited a decreased Singh index and an increased intracortical porosity compared with age-matched normal controls. By contrast, the osteoarthritic group showed no difference in osteon or Haversian dimensions, osteon number per unit area, Singh index, or in porosity compared with the nonfracture group. These morphometric differences found in the cortical bone of the medial femoral neck may play a role in the incidence of fractures.
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Management of displaced femoral neck fractures in young adults (a group at risk).
25 young adults (age 15-50 years) with femoral neck fractures were operated on an ordinary operating table, using a Watson-Jones approach. Open reduction of the fracture site through an anterior capsular incision was performed and fixation with three cancellous screws was done. Patients were regularly assessed for clinical and radiological evidence of non-union and avascular necrosis. Average follow-up was 32 months. Non-union was seen in one case (4 per cent) and evidence of avascular necrosis was seen in three cases (12 per cent). The results were compared with available published series of similar fractures, treated by closed and open reduction technique. The comparison showed that in young adults, primary open reduction and internal fixation of femoral neck fractures can be recommended as the treatment of choice.
Adolescent↗
[Surgical technic in femoral neck fractures].
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Femoral Fractures↗
Quality of life related to fracture displacement among elderly patients with femoral neck fractures treated with internal fixation. 2002.
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Age Factors↗
Retrospective analysis of factors influencing the operative result after percutaneous osteosynthesis of intracapsular femoral neck fractures.
A retrospective analysis of 104 patients with an intracapsular femoral neck fracture, treated with closed reduction and internal fixation showed that the Garden classification, the age of the patient and the quality of reduction and fixation are predictors for the final outcome. Fractures with a Garden classification of 1 and 2 have significantly better results than Garden 3 and 4 (P < 0.01). An unsuccessful reduction of the fracture and a poor surgical fixation technique had significant effect on the outcome (P = 0.01 and 0.02, respectively). If internal fixation is considered, the reduction and the technique of fixation should be perfect.
Adult↗