Contemporary management of femoral neck fractures: the young and the old

Efficacy of internal fixation alone versus combined pedicled bone grafting in young people with fresh Garden type III/IV femoral neck fracture: a systematic review and meta-analysis

BACKGROUND

This systematic review synthesizes current evidence on the efficacy of internal fixation combined with pedicled bone grafting (IFPBG) for treating fresh Garden type III/IV femoral neck fractures in young people.

METHODS

Registered prospectively in PROSPERO (CRD42024584036), we systematically searched PubMed, EMBASE, Web of Science and Cochrane Library databases from inception through August 20, 2024. Two reviewers independently performed data extraction and assessed methodological quality using the Institute of Health Economics appraisal checklist. Treatment outcomes and complications were analyzed through pooled rate calculations and odds ratio (OR) comparisons.

RESULTS

Three studies involving 353 patients met inclusion criteria, demonstrating generally robust methodological quality. The IFPBG group (Group A) showed superior fracture healing rates compared to internal fixation alone (Group B) (91.7% vs 67.7%; χ2 = 23.332, p < 0.001), with significant between-group differences in healing likelihood (OR = 5.53, 95%CI[2.98-10.28], p < 0.00001; I2 = 0%). Group A also demonstrated statistically lower risks of avascular necrosis (AVN) (OR = 0.22, 95%CI[0.10-0.46], p < 0.0001) and nonunion (OR = 0.22, 95%CI[0.09-0.57], p = 0.002). No intergroup differences emerged in wound infection or deep vein thrombosis rates.

CONCLUSIONS

Current evidence suggests IFPBG enhances fracture healing while reducing AVN and nonunion risks in young patients with displaced femoral neck fractures. Notwithstanding inherent limitations in included studies, these findings support further controlled trials to validate the therapeutic value of adjunctive pedicled bone grafting.

Closed Reduction Followed by Percutaneous Fixation of Acute Femoral Neck Fractures in Young Adults: A Retrospective Cohort Study

OBJECTIVES

To evaluate the surgical outcomes of femoral neck fractures (FNF) in young adults treated with a closed reduction technique because it pertains to reduction quality, rates of union, and risk factors for complication.

METHODS

DESIGN

Retrospective cohort study with radiograph and electronic medical record review.

SETTING

Level 1 Swiss Trauma Center.

PATIENT SELECTION CRITERIA

Between 2012 and 2021, young adults with isolated FNF (AO/OTA 31-B1) treated with percutaneous internal fixation were selected. Exclusion criteria were open reduction technique, age older than 65 years or younger than 16 years, pathologic fractures, and associated femoral head or shaft fractures.

OUTCOME MEASURES AND COMPARISONS

Primary outcome was quality of reduction, as assessed by 3 experienced trauma surgeons' evaluation of intraoperative and/or first postoperative radiographs using the overall impression, the Garden alignment index, and Lowell criteria. In addition, clinical outcomes, conversion to arthroplasty, and complications after closed reduction and fixation of femoral neck fractures were reviewed.

RESULTS

A total of 54 patients with a median interquartile range age of 57.5 (48-60) years were included. Among them, 22 (41%) were women and 32 (59%) were men. The closed reduction technique demonstrated satisfactory reduction results in up to 87% of cases. Major complications occurred in 19%, with 17% requiring conversion to total hip arthroplasty. Unacceptable or borderline acceptable reduction quality correlated significantly with the need for later conversion ( P = 0.03).

CONCLUSIONS

The study supported the use of the closed reduction technique for acute FNF in patients younger than 65 years, achieving satisfactory reduction results in up to 87% of cases with comparable complication rates to treatment of young femoral neck fractures with open reduction. Furthermore, it underscored the significance of the surgeon's overall impression of reduction quality, alongside the established reduction criteria, the Garden alignment index, and Lowell criteria, in evaluating the quality of the reduction. In addition, risk of conversion to total hip arthroplasty was associated with worse closed reduction quality.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Biomechanical Study of Three Cannulated Screws Configurations for Femur Neck Fracture: A Finite Element Analysis

Background

To improve the performance of cannulated screws (CSs) in the treatment of femoral neck fractures (FNF), a number of new screw configurations have been proposed. However, most of the studies have only analyzed the biomechanical performance of different screw configurations under static conditions. This study aimed to investigate the biomechanical performance of three cannulated screws configurations under different loadings through finite element analysis.

Methods

In this FEA study, nine numerical models of proximal femur were employed to analyze the mechanical response of various fracture types and different fixation strategies (three inverted triangular parallel cannulated screws (TCS), four non-parallel cannulated screws (FCS) and biplane double-supported screw fixation (BDSF) respectively). The maximum principal strain (MPS) on the proximal femur and the von Mises stress on the screws were compared for different models.

Results

In Pauwels I and II fractures, FCS had the lowest peak MPS on the proximal femur and the BDSF had highest peak MPS value. In Pauwels III fractures, BDSF performance in MPS is improved and better than FCS under partial loading conditions. FCS exhibits the lowest von Mises stress in all load conditions for all fracture types, demonstrating minimal risk of screws breakage.

Conclusions

FCS is an ideal screw configuration for the treatment of FNF. And BDSF has shown potential in the treatment of Pauwels type III FNF.

Treatment Failure After Repair of Displaced Femoral Neck Fractures in Patients Compared by "Decade of Life": An Analysis of 565 Cases in Adults Less Than 60 years of Age

OBJECTIVES

To study the results of displaced femoral neck fractures (FNFs) in adults less than 60 years of age by comparing patients, injury, treatment, and the characteristics of treatment failure specifically according to patients' age at injury, that is, by their "decade of life" [ie, "under 30" (29 years and younger), "the 30s" (30-39 years), "the 40s" (40-49 years), and "the 50s" (50-59 years)].

METHODS

DESIGN

Multicenter retrospective comparative cohort series.

SETTING

Twenty-six North American Level 1 Trauma Centers.

PATIENT SELECTION CRITERIA

Skeletally mature patients aged 18-59 years with operative repair of displaced FNFs.

OUTCOME MEASURES AND COMPARISONS

Main outcome measures were treatment failures (fixation failure and/or nonunion, osteonecrosis, malunion, and the need for subsequent major reconstructive surgery (arthroplasty or proximal femoral osteotomy). These were compared across decades of adult life through middle age (<30 years, 30-39 years, 40-49 years, and 50-59 years).

RESULTS

Overall, treatment failure was observed in 264 of 565 (47%) of all hips. The mean age was 42.2 years, 35.8% of patients were women, and the mean Pauwels angle was 53.8 degrees. Complications and the need for major secondary surgeries increased with each increasing decade of life assessed: 36% of failure occurred in patients <30 years of age, 40% in their 30s, 48% in their 40s, and 57% in their 50s (P < 0.001). Rates of osteonecrosis increased with decades of life (under 30s and 30s vs. 40s vs. 50s developed osteonecrosis in 10%, 10%, 20%, and 27% of hips, P < 0.001), while fixation failure and/or nonunion only increased by decade of life to a level of trend (P = 0.06). Reparative methods varied widely between decade-long age groups, including reduction type (open vs. closed, P < 0.001), reduction quality (P = 0.030), and construct type (cannulated screws vs. fixed angle devices, P = 0.024), while some variables evaluated did not change with age group.

CONCLUSIONS

Displaced FNFs in young and middle-aged adults are a challenging clinical problem with a high rate of treatment failure. Major complications and the need for complex reconstructive surgery increased greatly by decade of life with the patients in their sixth decade experiencing osteonecrosis at the highest rate seen among patients in the decades studied. Interestingly, treatments provided to patients in their 50s were notably different than those provided to younger patient groups.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Epidemiology and Management of Proximal Femoral Fractures in Italy between 2001 and 2016 in Older Adults: Analysis of the National Discharge Registry

This study aims to determine the annual incidence of proximal femoral fractures in Italy in the period between 2001 and 2016 among older adults, and to describe the trends in the clinical management of these cases. Data were retrieved from the National Hospital Discharge records issued by the Italian Ministry of Health and from the Italian Institute for Statistics. The number of hospitalizations increased between 2001 and 2016, while the age-adjusted yearly incidence decreased from 832.2 per 100,000 individuals to 706.2. The median age was 83 years (IQR 78-88) with a large majority of females (76.6%). The type of fracture varied with age in female subjects, with older women more frequently reporting pertrochanteric fractures. Therapeutic strategies for the different types of fracture depended on patients' age. During the study years, improvements in fracture classification and management strategies were observed, with a clear decreasing trend for non-operative solutions. In conclusion, the number of proximal femur fractures in older adults is growing, even if at a lower rate compared to population aging. The Italian surgical practice changed during the study period towards the implementation of the most recent guidelines.

Association between hyperglycemia on admission and preoperative deep venous thrombosis in patients with femoral neck fractures

Background

Elevated blood glucose is the most frequent electrolyte disturbance in acutely ill patients. This study aimed to determine whether admission hyperglycemia is associated with the incidence of preoperative deep venous thrombosis (DVT) in patients with femoral neck fractures.

Methods

This retrospective study was conducted on consecutive patients with femoral neck fractures admitted to our institution from March 2018 to March 2022. Blood glucose levels were measured within 24 h of admission and categorized into quartiles (Q1 = 5.30; Q2 = 5.70; Q3 = 6.60). Patients were divided into four groups (Group1-4) based on the quartiles. Preoperative DVT was diagnosed using venous compression ultrasonography. Multivariable logistic regression models and propensity score matching analysis evaluated the association between blood glucose and preoperative DVT in patients.

Results

Of 217 patients included in this study, 21(9.7%) had preoperative DVT in hospital, and admission hyperglycemia was observed in 83 (38.2%). Preoperative DVT was higher in patients with hyperglycemia (n = 15) than patients without hyperglycemia (n = 6) in the multivariable logistic regression models (OR 3.03, 95% CI 0.77–11.87). Propensity scores matching analyses manifested that compared with patients with group 2 (5.30 – 5.70 mmol/L) of glucose levels, the odds of preoperative DVT were slightly higher (OR 1.94, 95% CI 0.31–12.12) in patients with group 3 (5.70 – 6.60 mmol/L), substantially higher (OR 6.89, 95% CI 1.42–33.44, P trend < 0.01) in patients with the group 4 (> 6.60 mmol/L) of glucose levels.

Conclusions

In patients hospitalized for femoral neck fracture, markedly elevated blood glucose is associated with increased preoperative DVT in patients. The development of this biomarker could help in guiding patient counseling, risk assessment, and future management decisions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05862-0.

Treatment Failure in Femoral Neck Fractures in Adults Less Than 50 Years of Age: Analysis of 492 Patients Repaired at 26 North American Trauma Centers

OBJECTIVES

To assess the operative results of femoral neck fractures (FNFs) in young adults in a large multicenter series, specifically focusing on risk factors for treatment failure.

DESIGN

Large multicenter retrospective cohort series.

SETTING

Twenty-six North American Level 1 trauma centers.

PATIENTS

Skeletally mature patients younger than 50 years with displaced and nondisplaced FNFs treated between 2005 and 2017.

INTERVENTION

Operative repair of FNF.

MAIN OUTCOME MEASUREMENTS

The main outcome measure is treatment failure: nonunion and/or failed fixation, osteonecrosis, malunion, and need for subsequent major reconstructive surgery (arthroplasty or proximal femoral osteotomy). Logistic regression models were conducted to examine factors associated with treatment failure.

RESULTS

Of 492 patients with FNFs studied, a major complication and/or subsequent major reconstructive surgery occurred in 45% (52% of 377 displaced fractures and 21% of 115 nondisplaced fractures). Overall, 23% of patients had nonunion/failure of fixation, 12% osteonecrosis type 2b or worse, 15% malunion (>10 mm), and 32% required major reconstructive surgery. Odds of failure were increased with fair-to-poor reduction [odds ratio (OR) = 5.29, 95% confidence interval (CI) = 2.41-13.31], chronic alcohol misuse (OR = 3.08, 95% CI = 1.59-6.38), comminution (OR = 2.63, 95% CI = 1.69-4.13), multiple screw constructs (vs. fixed-angle devices, OR = 1.95, 95% CI = 1.30-2.95), metabolic bone disease (OR = 1.77, 95% CI = 1.17-2.67), and increasing age (OR = 1.03, 95% CI = 1.01-1.06). Women (OR = 0.57, 95% CI = 0.37-0.88), Pauwels angle ≤50 degrees (type 1 or 2; OR = 0.64, 95% CI = 0.41-0.98), or associated femoral shaft fracture (OR = 0.19, 95% CI = 0.10-0.33) had lower odds of failure.

CONCLUSIONS

FNFs in adults <50 years old remain a difficult clinical and surgical problem, with 45% of patients experiencing major complications and 32% undergoing subsequent major reconstructive surgery. Risk factors for complications after treatment of displaced FNFs were numerous.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Bipolar hemiarthroplasty may reduce cerebrovascular accidents and improve early weight-bearing in the elderly after femoral neck fracture

Cerebrovascular accidents (CVA) in the elderly population after femoral neck fracture remain great concern for physicians. Specifically, surgical fixation techniques, such as bipolar hemiarthroplasty (HA) and internal fixation play a significant role in influencing the occurrence of postoperative CVA in the elderly population.In order to identify 2 cohorts, we used a rigid selection process based on our institution's database. The cohorts were comprised of a HA cohort and a cannulated screw cohort, of which underwent femoral neck surgery, performed by 3 fellowship trained surgeons from 2003 to 2014. Risk factors were documented and measured, including Coumadin use and hypertension, and postoperative complications such as CVA and death rate were also recorded. A P-value of <.05 was determined to be statistically significant.A power analysis was performed and achieved a power of 0.95. We found a non-significant reduction in CVA for bipolar HA (3.6% CVA vs 0.0% in the non-CVA group, P = .48) and a non-significant increase in CVA for cannulated screw use (7.6% CVA vs 14.4% in the non-CVA group, P = .11). In addition, we found a significant difference in terms of weight-bearing status at 6-weeks postoperatively (0.95 vs 2.0, P < .0001), favoring the bipolar HA group.Among the advantages of bipolar HA surgery, surgeons should consider its value in reducing the occurrence of postoperative CVA. Furthermore, patients who underwent bipolar HA had improved weight-bearing status postoperatively compared with cannulated screw fixation.

A Rare Case of Simultaneous Fracture Neck of Femur on One Side and Contralateral Intertrochanteric Fracture Femur in a 41-Year-Old Female - A Case Report

Introduction

Simultaneous fractures in the neck of femur on the one side and contralateral intertrochanteric fracture of the femur with only trivial injury are among rarest injuries. Fracture neck of femur or intertrochanteric fracture either isolated or in combination such as simultaneous bilateral fracture neck of femur and simultaneous bilateral intertrochanteric fractures are relatively commonly reported in literature. Herein, we report a very rare case of a young female with chronic kidney disease who presented with simultaneous fractures neck of femur on the one side and contralateral intertrochanteric fracture of femur after a fall from standing height.

Case Report

A 41-year-old female with chronic kidney disease from the past 5 years presented to us with severe pain at both hip and inability to stand after a fall from standing height. Clinical examination and investigations were done. She suffered fracture neck of femur on the right side and intertrochanteric fracture femur on the left side. Single stage fixation of both these fractures by two different methods was done successfully after optimization of her medical condition with multidisciplinary approach. She was advised weight bearing according to fixation method used and progress of fracture union. She regained her preoperative walking status gradually in 6 months.

Conclusion

Simultaneous fractures in the neck of femur on the one side and intertrochanteric fracture of the femur on the other side are very rare presentation and can happen in patients with primary or secondary bone disease. Multidisciplinary team effort is needed for overall effective management and prompt surgical treatment can help achieve favorable outcome.

Treatment of Femoral Neck Fractures with Cannulated Screw Invasive Internal Fixation Assisted by Orthopaedic Surgery Robot Positioning System

OBJECTIVE

To investigate the clinical efficacy and advantages of cannulated screw internal fixation assisted by the orthopaedic surgery robot positioning system in the treatment of femoral neck fractures.

METHODS

The clinical data of 128 patients with femoral neck fractures which had been treated with cannulated screw internal fixation from January 2016 to July 2018 were retrospectively analyzed. Among them, 63 patients were treated with cannulated screw assisted by orthopedic robot positioning system (orthopaedic surgery robot group), and 65 patients were treated with traditional cannulated screw (traditional surgery group). The operation time, number of intraoperative fluoroscopy, number of guide needle placements, and the amount of operative blood loss were compared between the two groups. The success rate of one-time nail placement and the fracture healing rate were calculated. Fracture healing and internal fixation were observed. The hip joint function was evaluated by the Harris hip score 1 year after operation.

RESULTS

All patients were followed up for 12 to 24 months. The operation time was 65.70 ± 9.87 min in the robot group and 73.74 ± 9.78 min in the traditional group. The number of intraoperative fluoroscopy was 13.67 ± 4.39 times in the robot group and 17.09 ± 4.02 times in the traditional group. The number of guide needle placements was 9.95 ± 3.72 times in the robot group and 13.78 ± 4.39 times in the traditional surgery group. The success rate of one-time nail placement was 100% (63/63) in the robot group and 49.23% (32/65) in the traditional group. The amount of operative blood loss was 15.25 ± 6.21 mL in the robot group and 25.51 ± 6.97 mL in the traditional group. Compared with the traditional group, the robot group had shorter operation time, less fluoroscopy, less needle placement, less bleeding, and higher success rate of one-time nail placement. There was a significant difference between the two groups (P < 0.05). In the robot group, there was no infection, loosening of internal fixation, fracture displacement, and osteonecrosis of femoral head during the follow-up period. The fracture healing rate was 100% (63/63). In the traditional group, there were two cases of loosening of internal fixation and one case of osteonecrosis of femoral head during the follow-up period. The fracture healing rate was 100% (65/65). All patients were evaluated for hip joint function 1 year after operation. The Harris hip score in the robot group was 86.86 ± 4.74, and the Harris hip score in the traditional surgery group was 83.08 ± 5.44. Compared with the traditional group, the Harris hip score in the robot group was higher than that in the traditional group. There was significant difference between the two groups (P < 0.05). The excellent and good rate were 92.06% (58/63) in the robot group and 80% (52/65) in the traditional group. There was no significant difference between the two groups (P > 0.05).

CONCLUSION

Cannulated screw internal fixation assisted by the orthopaedic surgery robot positioning system is an ideal method for the treatment of femoral neck fractures. This method has the advantages of relatively simple operation, more accurate screw placement during operation, high success rate of one-time nail placement, short operation time, less surgical trauma, less radiation, and good recovery of hip function.

How do Orthopedic Surgeons Manage Displaced Femoral Neck Fracture in the Middle-Aged Patient? Brazilian Survey of 78 Orthopaedic Surgeons

Objective  The aim of the present study was to evaluate the practices and preferences of Brazilian orthopedic surgeons for the treatment of femoral neck fractures in middle-aged patients. Methods  A survey containing 10 images of femoral neck fractures was sent to a group of 100 orthopedic surgeons, all of them members of the Brazilian Society of Orthopedics and Traumatology. The questionnaire asked the treatment option for cases of nondisplaced and displaced fractures of the femoral neck in middle-aged patients, that is, those between 50 and 69 years old. Descriptive and inferential statistical analyzes were performed using the chi-squared (χ2) and the Fisher exact tests. The level of significance was 5%. Results  The survey was answered by 78% of the orthopedic surgeons invited to participate in the study. There was no significant difference in the treatment method distribution between generalists and specialists ( p  = 0.16) in the sample of nondisplaced femoral neck fractures. There was a highly significant difference in the treatment method distribution between generalists and specialists ( p  < 0.0001) in the sample of displaced fractures of the femoral neck. Conclusion  Preservation of the femoral head through multiple cannulated screws fixation is the treatment of choice for nondisplaced femoral neck fractures for both generalists and specialists. Low chronological and/or physiological age are the main factors for this decision-making. In displaced femoral neck fractures, femoral head replacement is preferred for both groups of orthopedists (generalists and specialists). In this situation, specialists prefer total hip arthroplasty (THA), whereas generalists favor partial hip arthroplasty (PHA).

The effect of patient, fracture and surgery on outcomes of high energy neck of femur fractures in patients aged 15-50

INTRODUCTION:

High-energy femoral neck fractures in young patients can be devastating, with the risk of osteonecrosis, nonunion, malunion and lifelong morbidity. The aim of this study is to define the effects of patient, fracture and surgical factors on the outcome of high-energy femoral neck fractures in patients aged from 15 to 50 years.

METHODS:

A retrospective review was conducted of high-energy femoral neck fractures in patients aged 15-50 managed surgically at a Level 1 Trauma Centre, using a prospectively recorded trauma database. Low energy trauma (including falls from <1 m), medical conditions adversely affecting bone density, and pathological fractures were excluded. A clinical and radiological review was performed. The primary outcome measures were the development of osteonecrosis or nonunion leading to total hip arthroplasty (THA). Secondary outcome measures included osteotomy or other surgical procedures, quality of reduction and malunion.

RESULTS:

32 patients meeting the inclusion criteria were identified between January 2008 and July 2015. The mean follow-up was 58.5 months (range 980-3,048 days). 3 patients (9.4%) required THA. No other surgical procedures were performed. None of the 29 other patients developed radiologically apparent osteonecrosis. Fracture type, displacement, anatomical reduction and fixation type were not statistically significant risk factors affecting these outcomes. For all patients, an average of 8% loss of femoral neck height and 10% femoral neck offset were seen.

CONCLUSIONS:

At a mean 4.9-year follow-up, the incidence of high-energy femoral neck fractures leading to THA was 9.4%, as a consequence of osteonecrosis or nonunion. Malunion was common.

Effect of cannulated screws with deep circumflex iliac artery-bone grafting in the treatment of femoral neck fracture in young adults

OBJECTIVES

Surgical treatment of femoral neck fracture in young adults is clinically challenging due to the high incidence of avascular necrosis of femoral head and fracture nonunion. The objective of this study is to evaluate the effectiveness of cannulated screws with deep circumflex iliac artery bone grafting (DCIABG) by comparing to the routinely used method in the treatment of femoral neck fracture in young adults.

METHODS

From March 2006 to December 2012, a total of 185 patients with femoral neck fracture were admitted to the hospital for internal fixation surgery, 103 patients (61 males and 42 females, mean age of 39.1 years) were treated with three cannulated screws with DCIABG (group A), and 82 patients (49 males and 33 females, mean age of 35.5 years) were treated with three cannulated screws without DCIABG (group B).

RESULTS

All patients were followed up for at least 24 months after the surgery. The patients in group A had a significantly higher Harris Hip Score (p < 0.001), shorter fracture healing time (p < 0.001), lower occurrence rate of avascular necrosis of femoral head (p = 0.008) and fracture nonunion (p = 0.012) compared to the patients in group B. However, the operation time and intraoperative blood loss were significantly lower in patients in group B than those in group A (p < 0.001).

CONCLUSIONS

Cannulated screws with DCIABG significantly reduced femoral head osteonecrosis and fracture nonunion. Therefore, it is a feasible and effective method in the treatment of young adult patients with femoral neck fracture.

Femur neck fracture in young adults, is it really an urgent surgery indication: retrospective clinical study

Introduction

Femur neck fracture comprises a significant part of intracapsular femur fracture in the intracapsular area of proximal femur and it is mostly seen in elder people. However, these kinds of fractures may be seen in young adults. The present study aims to search factors that affect femoral neck fractures in young adults after surgery carried out by internal determination method.

Methods

Files of patients who were applied internal determination through closed reduction and cannulated screw because of intracapsular femur neck fractures between 2010 and 2015 were analyzed retrospectively. Fractures were evaluated by means of Garden classification, which is based on radiological appearance. The cases were examined in terms of timing of surgery in two groups. Cases operated in the first 24 hours after trauma consisted of group 1 and after 24 hours group 2. Radiological staging in femoral head avascular necrosis was evaluated by Ficat-Arlet classification system whereas acetabular fractures and hip functionality was evaluated by Letournel and Judet system, which is based on direct graph of fracture line.

Results

Mean age at the time of surgery for 31 cases included in the study was 40.04 ± 9.63 year. The average duration from injury to surgery was 6.6 (1-20) days. Thirty nine percent of fractures was nondisplaced whereas 61% was displaced. The average follow-up period was 4.9 ± 1.35 years. The rate of nonunion was found 16% and femoral head avascular necrosis 6.4%. According to Judet System, 67.7% of cases showed excellent/good and 32.3% moderate/bad functional results. Six cases had a secondary surgery. Cases who had displaced fractures statistically showed worse functional results and underwent more secondary surgery than patients with nondisplaced fractures (P>0.05). As a result of logistic regression analysis, presence of displacement was a factor negatively affecting the judet score but did not affect the rate of complication. There were no significant differences between the two groups according to the surgical timing in terms of functional outcomes and complications.

Conclusion

Because of surgical treatment of femoral neck fractures in the first 24 hours does not affect functional outcomes and complication rate, surgery is recommended in optimal conditions. In the case of displacement, care must be taken in terms of poor functional results.

MORTALITY AND FUNCTION AFTER SURGICALLY-TREATED HIP FRACTURE IN ADULTS YOUNGER THAN AGE 60

OBJECTIVE

Hip fractures in young adults can cause poor functional capacity throughout life because of several complications. The purpose of this study was to prospectively evaluate 1-year mortality and functional outcomes for patients aged 60 years or younger with hip fracture .

METHODS

We prospectively obtained data for all consecutive patients aged 60 or younger with any type of hip fracture who were treated operatively between 2008 and 2014. After one year, patient outcomes were evaluated according to changes in pain severity, functional status (modified Barthel index), and mortality rate .

RESULTS

Of the total of 201 patients, 132 (65.7%) were men (mean age: 41.8 years) and 69 (34.3%) were women (mean age: 50.2 years) (p<0.001). Reduced pain severity was reported in 91.5% of the patients. The mean modified Barthel index was 22.3 in men and 18.6 in women (p<0.001). At the one-year follow-up, 39 cases (19.4%) were dependent on walking aids while only 17 patients (8.5%) used walking aids preoperatively (p<0.001). Seven patients (4 men and 3 women) died during the one-year follow-up period; 2 died in the hospital after surgery .

CONCLUSION

Hip fractures in young adults have a low mortality rate, reduction in pain severity, and acceptable functional outcomes one year after surgery. Level of Evidence II, Prospective Comparative Study.

Comparison of 3 Different Perioperative Care Models for Patients With Hip Fractures Within 1 Health Service

INTRODUCTION

Orthogeriatric care models have been introduced within many health-care facilities to improve outcomes for hip fracture patients. This study aims to evaluate differences in care between 3 models, an orthopedic model, a geriatric model, and a comanaged model.

MATERIALS AND METHODS

A retrospective analysis was conducted for hip fracture patients treated at Western Health between November 2012 and March 2014. All patients aged 65 years or older were included in the analysis.

RESULTS

There were 183 patients in the orthopedic model, 137 in the geriatric model, and 126 in the comanaged model. Demographics and clinical characteristics were similar across the 3 models. Length of stay, mortality, and discharge destination were also consistent across the 3 groups. However, groups involving geriatricians were more likely to receive preoperative medical assessments, have greater recognition of postoperative medical problems, and have implementation of long-term osteoporosis management.

CONCLUSION

The involvement of geriatricians in perioperative care models resulted in more comprehensive medical care without impacting length of stay, mortality, or discharge destination.

[Femoral neck fractures in young patients]

Femoral neck fractures in young patients are rare but of high clinical relevance due to the complexity of risk factors and complications. Early stabilization and accurate reduction are of high priority. Femoral head-preserving stabilization by dynamic hip screws or threefold screw osteosynthesis are the methods of choice. Postoperative results should be closely controlled in every case in order to be able to treat possible complications in time.

Emergency department evaluation and treatment of acute hip and thigh pain

Although the incidence of hip fractures is decreasing, the overall prevalence continues to increase because of an aging population. People older than 65 suffer fractures at a rate of 0.6% per year--2% per year for persons older than 85. One in 5 patients suffering a hip fracture will die within a year. Additionally, the emergency physician must consider entities such as avascular necrosis, compartment syndrome, and muscular disruption. This article reviews patterns and complications of acute hip and thigh injuries and clinically relevant diagnostic, anesthetic, and treatment options that facilitate timely, appropriate, and effective emergency department management.

Young femoral neck fractures: are we measuring outcomes that matter?

INTRODUCTION

Femoral neck fractures in younger aged patients are particularly devastating injuries with profound impairments of quality of life and function. As there are multiple differences in patient and injury characteristics between young and elderly femoral neck fracture patients, the geriatric hip fracture literature is unlikely to be generalisable to patients under age 60. We conducted a systematic review to determine if clinically relevant outcome measures have been used in previously published clinical studies of internal fixation in young adults with femoral neck fractures.

METHODS

We conducted a comprehensive literature search using multiple electronic databases and conference proceedings to identify studies which used internal fixation for the management of femoral neck fractures in patients between the ages of 15 to 60. Eligibility screening and data abstraction were performed in duplicate. We classified the reported outcomes into the following categories: operative and hospital outcomes, radiographic outcomes, clinical outcomes, and functional outcomes and health-related quality of life. We calculated the frequencies of reported outcomes.

RESULTS

Fort-two studies met our inclusion criteria. Operative and hospital outcomes were poorly reported with less than one-quarter of studies reporting relevant data. Important radiographic outcomes were also inadequately reported with only one-third of studies reporting the quality of the fracture reduction, and methods for assessment were highly variable. The assessment of avascular necrosis was reported in almost all the included studies (95.2%); however, the assessment of nonunion was only reported in three-quarters of the studies. Re-operations were reported in 73.8% of the included studies and the assessment of fracture healing was only reported in two-thirds of the studies. Less than half of the studies reported functional outcomes or health-related quality of life (overall patient evaluation scales and systems (45.2%), patient functional outcomes (30.9%), and health-related quality of life (4.8%).

DISCUSSION

Our systematic review found that the assessment of clinically relevant outcomes in the young femoral neck fracture literature is lacking, which makes utilising the literature to guide clinical practice challenging. Future studies should aim to include important radiographic measures, fracture-healing complications, functional outcomes, and health-related quality of life during any assessment of young femoral neck fracture treatment.

Efficacy evaluation for the treatment of subcapital femoral neck fracture in young adults by capsulotomy reduction and closed reduction

BACKGROUND

Subcapital femoral neck fracture in young adults has many complications, and the incidence is increasing year-by-year. The selection of the proper operation method to avoid them is an ambiguous matter. This study aimed to evaluate the treatment effect of subcapital femoral neck fracture by the capsulotomy and internal fixation with iliac bone grafting or closed reduction and internal fixation in young adults.

METHODS

From March 2003 to February 2010, 65 young patients with subcapital femoral neck fractures were treated, including 39 males and 26 females with average age of 34.5 years (range, 19-50 years); 29 cases of the left side and 36 cases of the right side. They were randomly divided into Group A with 34 cases treated by closed reduction and internal fixation and Group B with 31 cases treated by the capsulotomy and internal fixation with iliac bone grafting. The two groups had no significant differences in sex, age, body mass index and preoperative Harris Hip Score. The observation criteria involved the length of the incision, blood loss, operation time, nonunion rate, avascular necrosis of the femoral head (ANFH) rate and Harris Hip Score.

RESULTS

Four of 65 patients were lost follow-up, and the follow-up rate was 93.8%, the average follow-up time was 38.7 months (range, 33-47 months). In Group A, the incision length was 5.1 ± 2.2 cm, blood loss was 84.0 ± 13.2 ml, and operation time was 52.9 ± 10.2 min. In Group B, the incision length was 15.4 ± 4.6 cm, blood loss was 396.0 ± 21.3 ml, and operation time was 116.5 ± 15.3 min. Nonunion occurred in 8 patients (25.2%) in Group A and 1 patient (3.3%) in Group B. ANFH occurred in 9 patients (29.1%) in Group A and 2 patients (6.7%) in Group B. Postoperative Harris Hip Score was 89.0 ± 5.6 in Group A and 95.0 ± 4.5 in Group B. The above index of two groups was considered statistically significant (P < 0.05).

CONCLUSIONS

Capsulotomy and internal fixation with iliac bone grafting can improve fracture healing, reduce ANFH in young adults. It is a safe and effective operation for subcapital femoral neck fracture.

PET/CT study of temporal variations in blood flow to the femoral head following low-energy fracture of the femoral neck

Earlier studies on femoral neck fractures have assessed the blood flow in either the pre- or postoperative period and information is lacking regarding changes in vascular flow to the femoral head after injury. Sixty-two adults with low-energy intracapsular femoral neck fractures were studied prospectively. Mean patient age was 57.2 years (range, 45-82 years). All patients underwent positron emission tomography/computed tomography (PET/CT) prior to surgical intervention and 6 weeks after internal fixation. Internal fixation was done using cannulated cancellous titanium screws and serial follow-up radiographs were obtained (at monthly intervals for the first 3 months followed by 3 monthly intervals between radiographs up to 2 years). On the preoperative PET/CT, 13 patients showed intact vascularity, 31 showed total loss of vascularity, and 18 showed partial loss of vascularity of the femoral head. The 6-week postoperative PET/CT scan showed recovery of blood supply in 23 of the 31 patients with total loss of vascularity and 15 of the 18 patients with partial loss of vascularity of the femoral head. Eleven of 62 patients had total or partial avascularity at the 6-week postoperative PET/CT scan and all 11 patients showed evidence of avascular necrosis on plain radiographs at the end of 2 years. The association between the vascular status of the femoral head at 6 weeks and avascular necrosis at the end of 2 years was statistically significant (P<.001). This study shows that the femoral head undergoes temporal variations in blood flow following femoral neck fracture. Decreased or absent vascularity is seen in approximately 75% of the fractures and 80% of the femoral heads with initial vascular compromise seem to regain blood flow within 6 weeks. Thus, prognostication about vascularity based on single-point preoperative imaging is difficult. The 6-week postoperative PET/CT scan seems to be reliable in predicting the future status of the femoral head. However, decision making regarding hemiarthroplasty or internal fixation at the time of injury may have to depend on factors other than the preoperative vascular status of the femoral head.

Long-term follow-up results of delayed fixation of femoral neck fractures in adults

Background

Femoral neck fractures are urgent injuries that require precise reduction and stable fixation. In some cases, however, early treatment is not possible.

Objectives

The present study aimed to evaluate long-term results of delayed fixation of femoral neck fractures using cannulated screws.

Patients and Methods

This retrospective descriptive-analytical study was conducted on 26 patients with femoral neck fractures. The patients were treated through a closed reduction and fixation method using cannulated screws. Patients were followed up for at least five years and the rate of complications was determined.

Results

In this study, 26 patients with mean age of 34.3 years were assessed. Average time interval from injury to surgery was 46.4 ± 12.2 hours; 18 patients (69%) were operated on with more than 36 hours of delay. Incidence of AVN and nonunion was reported in 10 (38.4%) and 3 (11.5%) patients, respectively.

Conclusions

Time plays an important role in treatment results of femoral neck fractures. To treat the fractures, closed reduction and fixation using cannulated screws may still be the best option.