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PubMed2002

Primary hemiarthroplasty in old patients with displaced femoral neck fracture: a 1-year follow-up of 103 patients aged 80 years or more.

103 patients with displaced femoral neck fractures (Garden 3-4) treated with primary hemiarthroplasty in the Department of Orthopedics, Malmö University Hospital, Sweden 1998-1999 were followed in a prospective, consecutive study for 1 year. Inclusion criteria were age of at least 80 years, signs of mental changes and/or residence in an institution. The control group consisted of 69 patients with internal fixation (Hansson hook pins). The arthroplasty group required more blood transfusions, a longer operation and had more superficial infections. No differences were detected as regards other complications, length of hospital stay, in-hospital mortality or ability to return home. The 1-year mortality rates were similar in the arthroplasty (29/103) and control groups (28/69). Within 1 year, we found a lower failure rate in the arthroplasty group (6/103) than in the control group (18/69). In the arthroplasty group, 2/103 had dislocations. Of the surviving arthroplasty patients at 12 months, 31/74 could walk as well as before the fracture and 55/74 had no pain. We recommend primary hemiarthroplasty for demented and/or institutionalized patients over 80 years with displaced femoral neck fractures.

Age Factors↗
PubMed2005

The value of washers in cannulated screw fixation of femoral neck fractures.

BACKGROUND: Given the limited evidence to support the technical aspects of screw placement for treatment of femoral neck fractures, we conducted an observational study to evaluate demographic and radiographic variables associated with fixation failure. METHODS: Eligible patients with femoral neck fractures were treated with multiple cannulated screws across three academic centers during a 6-year period. The following variables were evaluated for their predictive value for fixation failure: age, gender, fracture type, presence of comminution, total number of screws, the absence of a washer, the screw configuration, reduction quality, the distance of the most inferior screw to the inferior neck, and screw alignment. Variables were evaluated separately and in a multivariable regression model. RESULTS: Eighty patients were included in the study. The overall failure rate was 30%. We identified four variables associated with fixation failure. These included the lack of washers (odds ratio [OR], 11.2; p = 0.03), imperfect quality of reduction (OR, 9.7; p < 0.01), age greater than 75 years (OR, 5.1; p = 0.04), and displaced versus undisplaced fracture type (OR, 3.8; p < 0.01). These four variables accounted for 43% of the variability in fixation failure (R(2) = 0.43). All other variables including the distance of the most inferior screw to the inferior/medial neck were found to be not significant. CONCLUSION: This study confirms previous findings in the literature that increased age, a displaced fracture type, and poor reduction increase the risk of fixation failure. Contradictory to current belief, there was no significant association between the distance of the inferior screw to the inferior/medial femoral neck cortex and fixation failure. A novel finding of the present study is that the use of washers significantly decreases the risk of fixation failure.

Adult↗
PubMed1983

[Treatment of femoral neck fractures using a total hip prosthesis].

From October 1. 1977 to December 1. 1982 106 patients suffering from fractures of the femoral neck (n = 75) or necroses of the femoral head and nonunions of the neck fracture respectively (n = 33) underwent total hip replacement by TEP (type Müller-Charnley). The results obtained were much better in comparison to other methods of treatment: less complications, shortening of in-hospital stay (average 21.1 days) and satisfactory till good late results in 82.8%. The mortality rate came up to 13.9% (fractures: 20.0%, necrosis of the head and nonunion: 0.0%). Concerning complications we observed wound infections 0.9%, dislocations 1.9%, twice fractures of the thigh bone, twice loosening of the shaft of the prosthesis and once its fracture. The authors emphasize that in spite of the good results obtained for the time being total hip replacement for fractures of the femoral neck should be reserved to special wards.

Female↗
PubMed1991

Verified causes of failure in the treatment of femoral neck fractures with multiple Knowles pins.

The authors examine 152 cases of femoral neck fractures treated with Knowles pins in order to analyze the incidence and causes of nonunion and avascular necrosis. The displaced fractures were all treated with closed reduction, and weight-bearing was permitted after 30-45 days. Seventy fractures were followed up after an average of four years. Criteria are proposed for evaluating the quality of both the reduction and the internal fixation. Healing was achieved in all cases of Garden grade I and II fractures; the incidence of avascular necrosis was 4.1%. In the displaced fractures the incidence of nonunion was 15.2% and avascular necrosis 13%. Technical errors in either reduction or internal fixation were present in 50% of the necroses and in 100% of the nonunions. The quality of the reduction was the most important factor in fracture healing, yet an accurate reduction and a valid fixation could not completely overcome the risk of avascular necrosis in the femoral head.

Adult↗
PubMedDate not supplied

Internal fixation of femoral neck fractures with posterior comminution: a biomechanical study.

OBJECTIVES: This study was performed to determine whether four cancellous lag screws provide significantly improved rigidity and fixation strength compared with three screws for fixation of displaced femoral neck fractures with posterior comminution. DESIGN: Biomechanical cadaver study. INTERVENTION: Eight pairs of mildly osteopenic femurs were selected, and each pair was fixed with three or four cancellous lag screws (randomly assigned) after the creation of a simulated femoral neck fracture with posterior comminution. A separate comparison with an unmatched group of six similar femurs with a simulated femoral neck fracture without posterior comminution and instrumented with three screws was performed to investigate the effect of posterior comminution. MAIN OUTCOME MEASUREMENT: The specimens were non-destructively tested to determine fixation rigidity in axial and anterior loading. Cyclic axial loading was then performed for 10,000 cycles; the femurs were retested for rigidity and finally were axially loaded until failure. RESULTS: The femurs with a posterior defect stabilized with three screws had significantly less resistance to axial and anterior displacement and sustained significantly lower axial loads to failure than those stabilized with four screws. The specimens instrumented with three screws without a posterior defect exhibited greater resistance to displacement in anterior loading and sustained greater axial loads to failure than those with a posterior defect stabilized with three screws. CONCLUSION: This study suggests that there are benefits to using four screws for fixation of femoral neck fractures with posterior comminution.

Biomechanical Phenomena↗
PubMed2000

Internal fixation versus total hip arthroplasty in the treatment of displaced femoral neck fractures: a prospective randomized study of 100 hips.

100 patients 75 years or older, with displaced femoral neck fractures, were randomly assigned to osteosynthesis with two parallel and percutaneously inserted screws (Olmed) or total hip arthroplasty (Lubinus IP). Mean age was 84 (75-101) years, 74% were women and 45% had mental dysfunction. General complications were commoner in the arthroplasty group but the mortality rates did not differ. In the osteosynthesis group, fracture complications were seen in 27/50 hips. In the arthroplasty group, dislocation was the main complication and occurred in 11/50 cases. At 3 months and after 1 year, the Harris Hip Scores were significantly better in the arthroplasty group. When mental dysfunction was present, the dislocation rate after arthroplasty was 32%, whereas the reoperation rate after osteosynthesis was 5%. The opposite pattern of complications was found in patients with normal mental function, 12% versus 60%. The 2-year mortality rate among those with mental dysfunction was 26/45, compared to 7/55 of those with normal function (p < 0.001). We conclude that total hip arthroplasty should be considered for a displaced femoral neck fracture in old patients with normal mental function and high functional demands.

Aged↗
PubMed2001

[Treatment of femoral neck fractures in the elderly patients with the compression screw].

The treatment of 50 patients above 70 years with femoral neck fractures were reviewed. All the patients were treated by internal fixation with the compression screw. Followed-up 1-5 years reviews showed that the rate of fracture union was 83%, the satisfactory rate of the function was 96%, no death was found. It is suggested that internal fixation with compression screw may be a good treatment in the elderly patients with femoral neck fractures.

Aged↗
PubMedDate not supplied

A prognostic algorithm for assessment of subcapital femoral neck fractures.

A new method for prognostication of non-union in subcapital femoral neck fractures is presented. From routine pre- and post-operative films from 112 patients with Garden stage 2, 3, and 4 fractures 4 parameters were obtained: Cranial displacement, orientation of the nail in the femoral head, depth of nail inserted, and attainment of perfect reduction. These 4 variables were combined into a simple algorithm capable of non-union prediction at various levels of certainty (74-100%).

Adult↗
PubMed2003

Costs of care after hospital discharge among women with a femoral neck fracture.

A prospective study was done among women who are postmenopausal and who had a displaced femoral neck fracture. The objective was to identify potential predictors of medical care costs during the 1-year after hospital discharge, and to examine the impact of the type of surgical procedure. The design was a 1-year prospective cohort study reflecting day-to-day clinical practice. At four hospitals, 84 women 50 years or older with a displaced femoral neck fracture were enrolled on a consecutive basis. Direct costs of medical care were documented during the 1-year after hospital discharge. Multivariate analyses were done to explore potential predictors of costs. Three fracture groups were defined by the time of surgical repair. Patients in the total hip arthroplasty group were significantly younger than those in the hemiarthroplasty and the internal fixation groups (mean age, 71 years, 81 years, and 80 years, respectively). The mean direct costs of medical care during the 1-year followup after hospital discharge were not significantly different after total hip arthroplasty, hemiarthroplasty, or internal fixation because of large cost variations among patients. A multivariate model identified increasing age and living in an institution at the time of the injury as the two significant determinants of increased medical costs during the 1-year followup after hospital discharge. Direct costs of medical care during the 1-year after hospital discharge do not seem to be associated with the type of surgical procedure. Increasing age and living in an institution at the time of the injury are strong predictors of increased costs.

Aftercare↗
PubMedDate not supplied

Anterior femoroacetabular impingement after femoral neck fractures.

OBJECTIVES: To verify whether anterior femoroacetabular impingement can be a reason for hip pain and loss of motion in patients with a healed femoral neck fracture. DESIGN: Retrospective clinical, radiologic, and surgical evaluation. SETTING: Third referral hospital. PATIENTS: Nine patients who previously sustained a femoral neck fracture were treated between 1995 and 1999 for hip pain and loss of motion. All these mostly young patients (mean age 33.3 years) complained of groin pain. During the physical examination, acute pain could be elicited by passively forcing the femoral neck against the acetabular rim in flexion, adduction, and internal rotation, motions that were all limited. METHODS: Conventional radiographs and, if possible, arthrographic magnetic resonance imaging scans were followed by a surgical subluxation or dislocation of the femoral head to analyze the sequelae of anterior femoroacetabular impingement. Treatment was based on improvement of the anterior offset (the difference between the anterior contour of the head and the femoral neck) or intertrochanteric osteotomy to ameliorate clearance of the joint. RESULTS: Intraoperatively in eight patients (one not operated), impingement was found to result from insufficient reduction of the fracture, already visible on the conventional radiographs. Retrotorsion (mean 20 degrees) of the head caused anterior impingement in all patients, additional varus position (mean caput collum diaphysis angle 115 degrees) of the head caused anterolateral impingement in two patients. In all patients, anterior labral and adjacent acetabular cartilage lesions were found during surgical subluxation or dislocation of the femoral head, comparable to those seen on the magnetic resonance imaging scan. They proved to result from repetitive abutment and compression between the head-neck junction and the acetabulum. CONCLUSION: Femoroacetabular impingement can be a cause for hip pain and loss of motion in patients who previously sustained a femoral neck fracture. The condition causes degenerative anterior labral and adjacent acetabular cartilage lesions. Early treatment is essential to prevent further degeneration and osteoarthrosis of the joint. Prevention is predicated by initial precise anatomic reduction of such fractures in all planes.

Acetabulum↗
PubMed1985

Factors influencing the incidence of reoperation after femoral neck fractures.

This investigation compares two groups of patients with fractures of the femoral neck: 22 required a further operation and 72 did not. Special attention was paid to osteoporosis, the displacement of the fracture, viability of the femoral head, operative impaction and osteosynthesis with a Thornton nail or three Scand hip pins. There was a significant (p less than 0.01) difference between the two groups with regard to osteoporosis, fracture displacement and viability of the femoral head. Scand hip pins, as compared to Thornton nails, showed a tendency (p less than 0.1) to need a smaller number of reoperations. Operative impaction compared with no impaction showed no difference.

Aged↗
PubMed1980

Results and complications of femoral neck fractures.

Based on reports in the current literature concerning fractures of the femoral neck, two divergent conclusions are possible. The first is optimistic about the results of treatment by contemporary methods. The second, by contrast, suggests that progress is much less than one might hope for. Over some of the factors that lead to treatment failures, one has little or no control. Over others, one has considerable control. It is in the latter that there are real expectations for improvement.

Bone Nails↗
PubMed1996

Primary and secondary Charnley-Hastings hemiarthroplasty in displaced femoral neck fractures and their sequelae.

298 women and 36 men, median age 80 (range 40-95) years with 340 femoral neck fractures were treated with Charnley-Hastings hemiarthroplasty and followed for 41 (range 12-86) months. 107 replacements were primary because of poor reduction and 233 were secondary, performed during 60 months after the injury because of disturbed fracture healing. The results of primary and secondary replacements regarding morbidity, mortality, prosthesis failure and survival were similar. The major postoperative complications were: early wound infection (10 cases, 2.9%), dislocation of the prosthesis (16 cases, 4.7%), fracture of femoral shaft (nine cases, 2.7%), and loosening of components with reoperation (six cases, 1.8%). In total 33 reoperations (9.7%) were performed. When failure of the prosthesis was defined as dislocation, fracture or removal of part or whole prosthesis, the three-year and six-year survival rates were 89 and 80%, respectively. Defining the failure as removal of prosthesis component(s) only, the success rates were 96 and 94%, respectively. We conclude that cemented bipolar prosthesis offers a good alternative for salvage of displaced or failed femoral neck fracture.

Adult↗
PubMed1982

Primary endoprosthetic replacement for acute femoral neck fractures. A review of 150 cases.

A review of 150 consecutive endoprosthetic replacements for acute displaced femoral neck fractures was undertaken to investigate the following serious criticisms of the method. The first is excessive hospital mortality and morbidity, especially in comparison to internal fixation procedures retaining the femoral head. The second is pain, derived from the "unphysiologic" nature of placing a metal prosthesis against otherwise normal acetabular cartilage. In the first instance the procedure is condemned as too major an operative procedure, poorly tolerated by elderly patients. In the second, it is a poor procedure if it requires revision in a patient incapable of withstanding more than one operation. A detailed follow-up shows that the in-hospital mortality in patients averaging 79.8 years of age, was 4%, lower than published mortality for either hemiarthroplasty or internal fixation. Close postoperative monitoring, antibiotic and antiembolic prophylaxis (2.0% infection, 6% embolic complications), and rapid mobilization contributed significantly to the increased survival. Painful endoprostheses, the most frequent complication, occurred in 16.7% of the 125 patients available for follow up at an average of 21 months. The causes of pain were considered technical problems judging prosthetic neck length, head size, sinking and loosening. Dissolution of the medial femoral neck was associated with a narrow stem prosthesis in five of six of these failures. The above statistics suggest that primary endoprosthetic replacement for displaced femoral neck fractures carries with it neither the excessive mortality and morbidity nor the pain induced potential for early reoperations that have been suggested by the recent literature.

Adult↗
PubMed1984

Radiologic morphometry in patients with femoral neck fractures and elderly control subjects. Comparison with histomorphometric parameters.

Radiologic morphometry was performed in 125 patients with femoral neck fractures and 74 elderly control subjects to evaluate simple parameters for screening of the population at risk. Reproducibility of metacarpal cortical thickness was high when measured in six metacarpals. Values of this parameter were similar in patients and control subjects. Reproducibility of the Singh index was poor. The patients with femoral neck fractures had a higher vertebral index, more vertebral crush fractures, and a lower Singh index than the control subjects. There was no significant difference in these radiologic indices between cervical and intertrochanteric fractures. The radiologic indices correlated poorly with each other and with histomorphometric data from transilial bone biopsies of the patients. Stepwise discriminant analysis allowed correct classification as patient or control subject in only 69.8% of the cases, with the Singh index having the highest predictive value. The reported observations indicate a need for a more accurate technique for local assessment of the bone mass in the femoral neck.

Aged↗
PubMed1987

Effects of strategy changes in the treatment of femoral neck fractures during a 17-year period.

From 1966 to 1982 new concepts in the treatment of fresh femoral neck fractures were introduced at a university hospital in Sweden. These included immediate postoperative weight-bearing, a program with rehabilitation at home in collaboration with primary care, and an alteration of the treatment policy from primary hemiarthroplasty to a flanged nail and finally to hook pins. The total annual number of hospital days was reduced by about one-third during this period in spite of the fact that the annual number of femoral neck fractures doubled. Thus, the mean hospitalization time decreased from 44 to 16 days. The proportion of patients admitted from their own homes decreased from 80% to 52% during the 17-year period, and for these, the return rate home at discharge from the hospital increased from 44% to 75%. According to several reports from Scandinavia, the number of hip fractures will double in the next two decades. Ways of further reducing the hospitalization time, new techniques, and, if possible, methods of preventing hip fractures must be sought.

Femoral Neck Fractures↗
PubMed1996

Occult femoral neck fractures in the elderly: optimisation of investigation.

AIMS: A relatively common clinical problem is the elderly patient who presents with strong clinical suspicion of femoral neck fracture, but normal initial radiographs. Our aim was to analyse the methods by which such a patient was investigated in a large hospital in New Zealand. We wished to determine the cost-effectiveness of current practice, in the light of recent trends overseas. METHODS: We retrospectively reviewed the records of 410 patients over 50 years of age presenting acutely to Auckland Hospital over a 12 month period, in whom trauma hip radiographs had been requested. We recorded initial radiographical diagnosis, admission or discharge following acute assessment, further radiological investigations, and the time taken to make the final diagnosis. RESULTS: Twenty-five patients with suspected occult femoral neck fracture underwent further radiological investigation, consisting of plain radiographs, scintigram, and CT, singly or in combination. The final diagnosis was achieved by repeat radiographs in 10 patients, and by scintigraphy in 15 patients. The time to arrive at the final diagnosis was on average 9.6 days when the diagnosis was made by radiographs, and 5.3 days when the diagnosis was made by scintigraphy. The overall average time taken to achieve the diagnosis was 7.0 days. CONCLUSIONS: Our analysis shows that the bed cost is the major expense incurred by the delayed diagnosis of a suspected occult femoral neck fracture. Various studies have shown the accuracy of magnetic resonance imaging in the assessment of these fractures. This practice is not yet routinely established throughout New Zealand. However, an urgent MRI study, performed at the time of initial assessment could markedly reduce the cost of managing this patient group.

Cost-Benefit Analysis↗