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PubMed2005

Comparison of internal fixation with total hip replacement for displaced femoral neck fractures. Randomized, controlled trial performed at four years.

BACKGROUND: Recent randomized, controlled trials performed at two years postoperatively have shown that a primary total hip replacement is superior to internal fixation for the treatment of a displaced femoral neck fracture in a relatively healthy, mentally competent, elderly patient. The primary aim of the present study was to evaluate the outcomes at four years. METHODS: One hundred and two patients (mean age, eighty years) who had an acute displaced femoral neck fracture were randomly allocated to be treated with total hip replacement or internal fixation. The inclusion criteria were an age of at least seventy years, absence of severe cognitive dysfunction, an independent living status, and the ability to walk independently. The main outcome measurements were hip complications, reoperations, hip function, and health-related quality of life. RESULTS: The mortality rate was 25% in both groups. At the forty-eight-month follow-up evaluation, the rate of hip complications was 4% in the patients treated with total hip replacement and 42% in those treated with internal fixation (p < 0.001) and the reoperation rates were 4% and 47%, respectively (p < 0.001). The arthroplasty group had no additional hip complications or reoperations between the twenty-four and forty-eight-month follow-up visits. In the fixation group, the percentage of hip complications increased from 36% to 42% and the percentage of reoperations increased from 42% to 47% during the same period. The hip function was significantly better and the decline in health-related quality of life was less pronounced in the arthroplasty group than it was in the fixation group at the four, twelve, and twenty-four-month follow-up evaluations. Ninety-seven percent of the patients in the arthroplasty group and 57% of the patients in the fixation group who were available for follow-up at forty-eight months had no hip complications (p < 0.001). CONCLUSIONS: Compared with internal fixation, primary total hip replacement provides a better outcome for mentally competent elderly patients with a displaced femoral neck fracture. The complication and reoperation rates were significantly lower and hip function and health-related quality of life were at least as good at four years after the surgery.

Aged↗

PubMed1999

Regional differences in cortical porosity in the fractured femoral neck.

Although bone mass is a contributory risk factor for intracapsular hip fracture, its distribution and porosity within the femoral neck is also important for bone strength. In femoral neck biopsies from 13 women with intracapsular hip fracture (mean +/- SEM: 75.4+/-2.1 years, OP) and 19 cadaveric samples (9 men and 10 women [control], aged 79.4+/-1.7 years), a segmental analysis was used to quantify circumferential variations in the characteristics of cortical bone haversian systems. In female control femoral necks, there was an increasing porosity gradient between the inferior (I) (7.7+/-0.6%) and superior regions (S) (16.05+/-1.8%,p < 0.005). In walking, these regions undergo compression and tension, respectively. In men, a similar trend was observed, but the differences were not significant (I: 11.1+/-1.2%; S: 14.1+/-1.7%; p = 0.133). This porosity gradient was not maintained in the fracture group (I: 10+/-1%; S: 12.65+/-1.2%). In contrast, porosity in the fracture group was greatest in the anterior cortex, being 41% higher in that quadrant than in controls (p = 0.06). The areal density of haversian canals ranged from 16.7 to 21.3 canals/mm2 with no significant differences between fractures and controls. In the control women, mean canal diameter was highest in the superior region (60+/-2.8 microm), and these canals were significantly larger than those in the inferior region (49.4+/-1.4 microm, p < 0.05). This difference was less marked in the fracture cases (I: 53.21+/-2.5 microm; S: 59.1+/-2.8 microm; p = 0.0878). Although the mean canal diameter in the anterior quadrant of the fracture cases was higher than in the control women this did not reach significance (OP/F: 59.5+/-3 microm; control/F: 52.7+/-2.6 microm; p = 0.106). However, the proportion of "giant" canals with diameters >385 microm (defined as the top 0.5% in the controls) was doubled in the anterior region of the fracture cases (OP/F: 1.28%; control/F: 0.69%; p < 0.005). Porosity is related to the square of the canal radius; therefore, such canals make a substantial contribution to cortical porosity. Previous work has shown that the elastic modulus of bone decreases approximately as the square root of porosity. Therefore, the increased porosity and the higher prevalence of "giant" canals have a markedly negative influence on the ability of the cortical shell to withstand stresses associated with a fall. The mechanisms responsible for the localized generation of "giant" haversian canals, and ultimately the "trabecularization" of the cortex, require further investigation.

Adaptation, Physiological↗

PubMed1987

Prediction of survival in patients with femoral neck fractures.

A prospective study of factors which might help to predict mortality in patients with intracapsular fractures of the femoral neck has been undertaken. A multivariate analysis technique was used to analyse the collected data, and it was found that mental ability was the most significant variable; this factor had the greatest effect on outcome.

Aged↗

PubMed1987

Atherosclerosis of the vessels in the ligamentum teres. Optical and electron microscopy findings in elderly patients with femoral neck fractures.

The ligamentum teres was studied in 20 subjects, aged from 64 to 83 years, with fractures of the femoral neck treated by prosthetic replacement during 1985. The arterioles were examined under a stereoscopic dissection microscope; they were further studied by optical and electron microscopy. Almost complete occlusion by typical proliferative atherosclerotic changes was a constant finding, thereby cutting off any significant vascular supply to the femoral head.

Aged↗

PubMed2002

[Femoral neck fracture in osteopoikilosis].

Osteopoikilosis was discovered in a 53-year-old patient who suffered a fracture of the right femoral neck. Plain X-rays demonstrated symmetrical bilateral stippling of variable size. No images were seen in the skull and spine. The fracture of the femoral neck was treated by total hip replacement. At surgery, the joint cartilage of the femoral head and the acetabulum had a normal aspect. Pathology examination of the femoral head demonstrated regular thick dense lamellae. Functional outcome at ten months was good (Postel-Merle-d'Aubigné score). Osteopoikilosis is an uncommon clinically latent condensing bone disease which can be revealed by bone fracture.

Arthroplasty, Replacement, Hip↗

PubMed1998

[Femoral neck fractures in childhood].

In a retrospective multicenter study we followed-up 30 fractures of the neck of the femur in children aged 11 years (1.5-15 years) for 4.8 years (0.5-20.0 years). It is the aim of this study to analyse factors possibly related to outcome, like age at injury, type of fracture, interval between injury and treatment, method of stabilization and postoperative interval until full weight bearing. At follow-up subjective parameters (pain, weather sensitiveness), clinical parameters (range of motion, claudication, leg length discrepancies) and radiological parameters (hip series) were investigated and medical charts and roentgenograms were reviewed using a standardized protocol. 29 of 30 children (96.7%) have sustained displaced fractures. Non-operative treatment has been applied in 4 children. 26 femoral neck fractures (type I: 1, type II: 8, type III: 17) were stabilized by internal fixation using screws and/or pins. Following non-operative treatment one child suffered a coxa vara and another child suffered a avascular femoral head necrosis in combination with coxa vara and leg length shortening of 4 cm. Following operative treatment 9 of 26 children (34.6%) suffered a avascular femoral head necrosis and 3 children (11.5%) suffered a coxa vara. In 6 of 26 children (23%) we observed leg length discrepancies > 2 cm. We were not able to demonstrate any significant follow-up result differencies between the groups of children who have sustained type II or type III fractures, or between the groups of children aged < 10 years when compared to children aged > 10 years, or between the group of children who were operated on within 6 hours after the accident when compared to the group of children operated > 6 hours after the accident. We observed no significant follow-up result differences between the groups of children who had different intervals between operation and full weight bearing. Operative fracture management remains the treatment of choice in the majority of displaced femoral neck fractures in children. However, in our limited study we were not able to demonstrate any significant follow-up result differences between the group of children treated by immediate open reduction and internal fixation (interval injury - operation < 6 hours) when compared to children who had been operated > 6 hours after the injury.

Adolescent↗

PubMed2005

High secondary displacement rate in the conservative treatment of impacted femoral neck fractures in 105 patients.

INTRODUCTION: The purpose of this retrospective study was to evaluate the dislocation rate after the conservative treatment of impacted femoral neck fractures in four hospitals with the same treatment protocol of partial weight-bearing when tolerated. PATIENTS AND METHODS: We reviewed the records of 105 patients (mean age 78 years) with an impacted femoral neck fracture, all primarily treated conservatively. Patient demographics, ASA classification and radiographic features were scored. RESULTS: Secondary displacement occurred in 48 patients (46%). There was no significant correlation (p > 0.05) between gender, age, ASA classification or Pauwels angle and secondary displacement. CONCLUSION: In our group of patients, secondary displacement was frequent and unpredictable.

Adolescent↗

PubMed1990

Serum copper levels in elderly patients with femoral-neck fractures.

The serum copper levels of 46 elderly patients with fractures of the femoral neck were assayed and found to be significantly lower than those of a group of controls matched for age and sex. These findings are consistent with nutritional copper deficiency which may contribute to the development of fractures by reducing bone strength.

Age Factors↗

PubMed1995

Comparison of chondroitin sulphate composition of femoral head articular cartilage from patients with femoral neck fractures and osteoarthritis and controls.

The glycosaminoglycan (GAG) and uronic acid (UA) composition of human hip articular cartilage from patients with femoral neck fractures [assumed osteoporosis (OP); n = 12], from patients with osteoarthritis (OA; n = 12) and from normal controls (n = 9) was determined. Full depth tissue samples from the control and OP groups were analysed from the superior, inferior, anterior and posterior regions, while the OA tissue was from cystic (tissue growing on top of cystic bone lesions) and osteophytic regions, from normal and fibrillated resident cartilage and from regions immediately adjacent to eburnated bone. The total sulphated GAG and UA content was reduced in the inferior region of control cartilage compared to the other regions and the values of all regions of the assumed OP group. Cystic regions and OA cartilage adjacent to the bone also showed lower GAG and UA levels than the other regions. The ratios of chondroitin 6-sulphate (C6S) to chondroitin 4-sulphate (C4S) indicated a similar pattern in the different regions of controls and the patient group with femoral neck fracture (OP group). The cystic and osteophytic cartilage of the OA group exhibited lower C6S/C4S ratios than any other region. The levels of dermatan sulphate (DS) in the cartilage of all regions of the OP and control groups were very similar and low, while the tissues of the OA group contained significantly higher amounts, particularly the cartilage from osteophytes. The previously presumed compositional similarity between normal aged and osteoporotic articular hip cartilage was essentially confirmed in a comparative analysis. Significant changes in GAG and UA composition of OA cartilage from distinct regions was also recorded.

Aged↗

PubMed1997

Bone and muscle mass after femoral neck fracture. A controlled quantitative computed tomography study of osteosynthesis versus primary total hip arthroplasty.

The cortical bone mineral density (BMD), bone volume, bone mass and muscle volume of the thigh, and the BMD of the distal femur and proximal tibia were measured quantified by quantitative computed tomography (QCT) after an operation for a displaced femoral neck fracture. Twenty patients were randomized to osteosynthesis or total hip arthroplasty (THA). Both legs were scanned after 18 months, and the operated side was compared with the healthy side. Clinical assessment was performed with a Harris hip score. A reference group of 9 patients, who had undergone THA because of arthrosis, was chosen. In the fracture patients, we found a 9% decrease in bone mass and muscle volume of the middle femur. The BMD of the distal femur and proximal tibia showed a more marked osteopenia. There was no difference in these parameters between the two groups. In the reference group of operated arthrosis patients, we did not find any differences between sides postoperatively. After the operation, the fracture patients had a lower Harris score than the arthrosis patients, and this was most pronounced among those who had undergone osteosynthesis. The finding of a marked osteopenia after a femoral neck fracture, irrespective of treatment, but no bone loss after THA because of arthrosis, implies that patients with a femoral neck fracture are more sensitive to osteopenia, and that the bone loss is not proportional to the operative trauma.

Aged↗

PubMed1995

Radiographic factors predicting non-union of displaced intracapsular femoral neck fractures.

After 82 patients underwent osteosynthesis with multiple pinning for a displaced intracapsular femoral neck fracture, 58 fractures were united, and 24 were not. These 82 patients were included in a discriminant analysis. Union and non-union groups were the dependent variables. Eleven presumably predictive factors measured on X-ray films obtained from these patients before and immediately after operation were taken as independent variables. Three radiographic factors were selected by a stepwise method according to the effect they had on union. These were: the distance of medial displacement between fragments before reduction; the varus angle after reduction; and the distance of medial displacement between fragments after reduction. The distance of medial displacement between fragments before reduction proved the most important factor in making a choice between osteosynthesis and primary arthroplasty, and it was revealed that osteosynthesis could not be expected to provide union if the distance was 20 mm or more. It was also confirmed that union was promoted, if the cranial fragment was reduced to a valgus position and the medial cortical bones were aligned as much as possible at the time of osteosynthesis.

Aged↗

PubMed2006

[Evaluation of complications of femoral neck fractures in children operated on at least 24 hours after initial trauma].

OBJECTIVES: We evaluated complications and the factors affecting the development of avascular necrosis of the femoral head in children who underwent surgery for femoral neck fractures after at least a 24-hour delay. METHODS: We reviewed the results of 22 children (11 boys, 11 girls; mean age 10 years; range 4 to 14 years) who were operated on after the first 24 hours for femoral neck fractures. According to the Delbet classification, two patients had type I, eleven patients had type II, and nine patients had type III fractures. Associated injuries were detected in seven patients. The mean duration from trauma to surgery was seven days (range 1 to 15 days). Internal fixation was performed following closed (n=20) or open (n=2) reduction. The results were assessed using the Ratliff criteria at the end of a mean follow-up of 73 months (range 18 to 184 months). The patients were evaluated with respect to age, type of fracture, displacement, complications, and avascular necrosis. RESULTS: The results were good in 12 (54.6%), fair in eight (36.4%), and poor in two patients (9.1%). Complications developed in 17 patients (77.3%), 12 of whom had more than one. The most frequent complication was premature physeal closure (n=14; 63.6%) followed by avascular necrosis (n=12; 54.6%). No significant differences were found (i) with regard to age and the type of fracture between patients with and without avascular necrosis, and (ii) with regard to avascular necrosis between patients who were treated within the first and second week of trauma (p>0.05). CONCLUSION: The results of surgery performed after the first 24 hours are mainly influenced by the occurrence of avascular necrosis and, secondarily, by the type of fracture.

Adolescent↗

PubMed2001

[Surgery of femoral neck fractures--higher rate of osteosynthesis failure with the use of 4,5 mm screws compared to 6,5 mm screws].

BACKGROUND: Displaced femoral neck fractures are usually treated with screw osteosynthesis or primary hip replacement (unipolar or bipolar). MATERIAL AND METHOD: In this retrospective study we compared the rate of early failure during two consecutive years using two different screw implants each year. The patient groups were demographically similar, and the relationships between the use of hip replacement and screws as primary treatment were similar in the two groups. In the first group (group A), two screws with a shaft and outer thread diameter both of 6.5 mm were used. In the second group (group B), two screws with shaft diameter of 4.5 mm and outer thread diameter of 7.3 mm were used. The number of patients operated with screws were 191 the first year and 177 the following year. RESULTS: The number of patients reoperated with a hip replacement within the first 100 days was 16 (8%) in group A and 29 (16%) in group B (risk difference 0.08; 95% CI 0.013-0.147). INTERPRETATION: We recommend that when two screws are used for fixation of femoral neck fractures, they should have a shaft diameter of at least 6.5 mm.

Aged↗

PubMed1999

Reorganization of nursing and medical care to reduce the incidence of postoperative delirium and improve rehabilitation outcome in elderly patients treated for femoral neck fractures.

The aim of this study was to evaluate the effectiveness of a nursing and medical intervention programme for the prevention and treatment of delirium in elderly patients treated for femoral neck fractures. Forty-nine patients consecutively admitted to an orthogeriatric rehabilitation unit in a county hospital in northern Sweden were compared with historical cohorts of corresponding patients in the same and other hospitals. There was a total reorganization of nursing and medical care of patients with femoral neck fractures. The intervention programme consisted of staff education, co-operation between orthopaedic surgeons and geriatricians, individual care and planning of rehabilitation, improved ward environment, active nutrition, improved continuity of care and prevention and treatment of complications associated with delirium. The main result of the study was that the incidence of delirium was significantly lower than in all previously published studies. The incidence of other postoperative complications was also lower, and a larger proportion of the patients regained independent walking ability and could return to their previous living conditions on discharge. It can be concluded that the intervention programme reduced the incidence and duration of delirium and improved functional outcome for elderly patients treated for femoral neck fractures.

Aged↗

PubMed1991

Internal fixation of femoral neck fractures. Two methods compared.

In a prospective randomised study, the Hansson pin technique for internal fixation of fractures of the femoral neck was compared with the Uppsala screw technique. The series consisted of 115 consecutive patients, 97 women and 18 men, with a mean age of 80 years. There were 56 patients treated with Hansson pins and 59 with Uppsala screws. After one year 22 patients had died, eight in the Hansson pin group and 14 in the Uppsala screw group (p = 0.28). Twenty-four complications had occurred, 18 in the Hansson pin group and six in the Uppsala screw group (p = 0.008). After exclusion of those with complications, the patients in the Hansson pin group had significantly more pain, less mobility, and a smaller proportion were living in their own homes.

Aged↗

PubMed1997

[Personal experience in rehabilitation of patients treated with Austin-Moore hip arthroplasty for femoral neck fracture].

Pre and post-operative rehabilitation protocol used in 76 patients with femoral neck fracture treated with Austin-Moore hip plasty is presented. The age of patients ranged from 68 to 91 years (mean 79 years). They were operated on average 5 days after admission (range 1-16 days). The authors emphasize role of rehabilitation leading to regaining of ambulating skills by the operated patient. It also decreases the number of pulmonary and psychoorganic complications, shortens hospital stay. Cardiac infarct and pulmonary vein embolism were causes of two fatalities in postoperative period. Mean hospital stay was 22 days.

Aged↗

PubMed2002

[Treatment outcome in femoral neck fractures].

Retrospective study of 372 patients with Garden III-IV type intracapsular femoral neck fractures performed in Clinic of Orthopedics and Traumatology, Kaunas University of Medicine, Kaunas Red Cross hospital. Ninety eight percent of them were operated: osteosynthesis for 302 patients, and arthroplasty for 63 patients. Evaluating results of treatment we paid attention on walking ability, pain in hip joint. Mean follow-up time was 1.5 years. Satisfactory results we received for 41.8%. The best results we received after total hip replacement and after osteosynthesis with modern fixation devices. Delayed surgery worsens results. Type of anesthesia did not influence results of osteosynthesis.

Aged↗

PubMed2005

Delirium is associated with poor rehabilitation outcome in elderly patients treated for femoral neck fractures.

The aim of this study was to describe risk factors for delirium and the impact of delirium on the rehabilitation outcome for patients operated for femoral neck fractures. Sixty-one patients, aged 70 years or older, consecutively admitted to the Department of Orthopaedic Surgery at Umeå University Hospital, Sweden for femoral neck fractures were assessed and interviewed during hospitalization and at follow up 4 months after surgery. Delirium occurred in 38 (62%) patients and those who developed delirium were more often demented and/or depressed. Patients with delirium were longer hospitalized and they were more dependent in their activity of daily living (ADL) on discharge and after 4 months. They had poorer psychological well-being and more medical complications than the nondelirious. A large proportion of the patients who developed delirium did not regain their previous walking ability and could not return to their prefracture living accommodation. Delirium after hip fracture surgery is very common especially among patients with dementia or depression. This study shows that delirium has a serious impact on the rehabilitation outcome from both short- and long-term perspectives. Because delirium can be prevented and treated, it is important to improve the care of elderly patients with hip fractures.

Activities of Daily Living↗