Angular stable multiple screw fixation (Targon FN) versus standard SHS for the fixation of femoral neck fractures

Dynamic Locking Plate versus Multiple Cancellous Screws for the Fixation of Intracapsular Femoral Neck Fractures: Long-Term Results and Quality-Of-Life Assessment Based on Patient-Reported Outcome Measures

The purpose of this study was to compare the long-term clinical outcomes and quality-of-life measures for two fixation methods in the setting of displaced femoral neck fractures. The two groups included fixation with multiple cancellous screws (group 1) and telescopic femoral neck screws and a small locking plate device (Targon FN) (group 2). Patients underwent reduction and internal fixation with either multiple cancellous screws or the Targon FN device from March 2000 to January 2012. Failure endpoints included nonunion, osteonecrosis of the femoral head, and revision surgery. Patient-reported outcome measures included chronic pain, ability to ambulate, and the use of ambulation assistive devices. Statistical analysis demonstrated a statistically significant lower rate of non-union and overall complication in the Targon FN group (p value < 0.001 and p value = 0.005, respectively). Logistic regression analysis showed that operative fixation with the Targon FN device decreased the odds ratio for overall complication by a factor of 0.34 (p = 0.02). There were no statistically significant differences between groups 1 and 2 in patient-reported outcomes (chronic pain (p = 0.21), ability to ambulate (p = 0.07), and the use of an ambulation assistive device (p = 0.07)). When compared to traditional cancellous screw fixation of femoral neck fractures, the Targon FN device has significantly lower complication rates and equivalent patient-reported outcomes.

Pinloc or Hansson pins: a multicenter, randomized controlled study of 439 patients treated for femoral neck fractures

Objectives

To compare the recently developed Hansson Pinloc system, which features 3 cylindrical parallel pins with hooks connected through a fixed-angle interlocking plate, with the Hansson Pin System (2 hook pins) for the treatment of femoral neck fractures.

Design

One hundred fourteen patients with displaced femoral neck fractures and 325 patients with nondisplaced fractures from 9 orthopaedic centers were randomized to either Hansson Pinloc system or Hansson Pin System and followed for 2 years or until death. Age at inclusion was 50 years or older.

Main Outcome Measurements

The primary outcome was failure (defined as early displacement, nonunion, symptomatic avascular necrosis, or deep infection). Secondary outcomes included revision surgery, Timed Up and Go (TUG) test and patient-reported outcome measures (PROMs: EQ-5D and WOMAC).

Results

For nondisplaced fractures, the incidence of failure was 14% (23/169) in the Pinloc group and 16% (25/156) in the Hansson group. For displaced fractures, the analysis was stratified by age. Patients aged 50-69 years with displaced fractures showed a 2-year failure rate of 44% (17/39) in the Pinloc group versus 44% (16/36) in the Hansson group. For patients 70 years or older with displaced fractures, 33% (7/21) in the Pinloc group versus 22% (4/18) in the Hansson group failed. At 3 and 12 months, no clinically significant differences between treatment groups were found for EQ-5D-3L, WOMAC, or for the TUG in any fracture type or age group.

Conclusions

There were no advantages for Pinloc in any of the studies aspects.

Level of evidence

1.

Novel slide compression anatomic plates of the femoral neck for treating unstable femoral neck fracture: A biomechanical study

To compare the biomechanical stability of slide compression anatomic plates of the femoral neck, cannulated compression screws and dynamic hip screws with derotation screws for stabilizing unstable femoral neck fractures (Pauwels angle = 70°). Pauwels III femoral neck fractures were created on 45 Sawbones femurs and randomly assigned to three implant groups (1:1:1). The biomechanical stability of all Sawbones in each treatment group was evaluated with three tests. First, in the static loading test, the load-displacement curve, vertical stiffness (load/vertical displacement [N/mm]) and 5 mm failure load were recorded. Second, in the incremental cyclic loading test (700, 1000, and 1400 N), the cyclic-displacement curve and the displacement of the fragments were recorded. Third, in the torsion test, the torsional rigidity, maximum torque, and torsional angle corresponding to the maximum torque were recorded. The static compression test showed that slide compression anatomic place-femoral neck (SCAP-FN) had the largest vertical stiffness (275 ± 11 N/mm, p < 0.01) and 5 mm failure load (1232 ± 156, p < 0.01). The cyclic loading test showed that SCAP-FN had the lowest change in displacement after 30000 cycles of loading. The torsional stiffness and the maximum torque followed the order SCAP-FN > dynamic hip screw systems (DHS) + derotational screw (DS) > CCS, and the torsional angle corresponding to the maximum torque followed the order SCAP-FN < DHS + DS < CCS. The SCAP-FN construct provides stiffness and stability compared with other standard fixation techniques (3CS and DHS + DS). The fixation strategy of SCAP-FN might be sufficient for clinical use, indicating studies in the human body are warranted.

Surgical interventions for treating intracapsular hip fractures in older adults: a network meta-analysis

BACKGROUND

Hip fractures are a major healthcare problem, presenting a considerable challenge and burden to individuals and healthcare systems. The number of hip fractures globally is rising rapidly. The majority of intracapsular hip fractures are treated surgically.

OBJECTIVES

To assess the relative effects (benefits and harms) of all surgical treatments used in the management of intracapsular hip fractures in older adults, using a network meta-analysis of randomised trials, and to generate a hierarchy of interventions according to their outcomes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Web of Science, and five other databases in July 2020. We also searched clinical trials databases, conference proceedings, reference lists of retrieved articles and conducted backward-citation searches.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs comparing different treatments for fragility intracapsular hip fractures in older adults. We included total hip arthroplasties (THAs), hemiarthroplasties (HAs), internal fixation, and non-operative treatments. We excluded studies of people with hip fracture with specific pathologies other than osteoporosis or resulting from high-energy trauma.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion. One review author completed data extraction which was checked by a second review author. We collected data for three outcomes at different time points: mortality and health-related quality of life (HRQoL) - both reported within 4 months, at 12 months, and after 24 months of surgery, and unplanned return to theatre (at end of study follow-up). We performed a network meta-analysis (NMA) with Stata software, using frequentist methods, and calculated the differences between treatments using risk ratios (RRs) and standardised mean differences (SMDs) and their corresponding 95% confidence intervals (CIs). We also performed direct comparisons using the same codes.

MAIN RESULTS

We included 119 studies (102 RCTS, 17 quasi-RCTs) with 17,653 participants with 17,669 intracapsular fractures in the review; 83% of fractures were displaced. The mean participant age ranged from 60 to 87 years and 73% were women.  After discussion with clinical experts, we selected 12 nodes that represented the best balance between clinical plausibility and efficiency of the networks: cemented modern unipolar HA, dynamic fixed angle plate, uncemented first-generation bipolar HA, uncemented modern bipolar HA, cemented modern bipolar HA, uncemented first-generation unipolar HA, uncemented modern unipolar HA, THA with single articulation, dual-mobility THA, pins, screws, and non-operative treatment. Seventy-five studies (with 11,855 participants) with data for at least two of these treatments contributed to the NMA. We selected cemented modern unipolar HA as a reference treatment against which other treatments were compared. This was a common treatment in the networks, providing a clinically appropriate comparison. In order to provide a concise summary of the results, we report only network estimates when there was evidence of difference between treatments. We downgraded the certainty of the evidence for serious and very serious risks of bias and when estimates included possible transitivity, particularly for internal fixation which included more undisplaced fractures. We also downgraded for incoherence, or inconsistency in indirect estimates, although this affected few estimates. Most estimates included the possibility of benefits and harms, and we downgraded the evidence for these treatments for imprecision.  We found that cemented modern unipolar HA, dynamic fixed angle plate and pins seemed to have the greatest likelihood of reducing mortality at 12 months. Overall, 23.5% of participants who received the reference treatment died within 12 months of surgery. Uncemented modern bipolar HA had higher mortality than the reference treatment (RR 1.37, 95% CI 1.02 to 1.85; derived only from indirect evidence; low-certainty evidence), and THA with single articulation also had higher mortality (network estimate RR 1.62, 95% CI 1.13 to 2.32; derived from direct evidence from 2 studies with 225 participants, and indirect evidence; very low-certainty evidence). In the remaining treatments, the certainty of the evidence ranged from low to very low, and we noted no evidence of any differences in mortality at 12 months.  We found that THA (single articulation), cemented modern bipolar HA and uncemented modern bipolar HA seemed to have the greatest likelihood of improving HRQoL at 12 months. This network was comparatively sparse compared to other outcomes and the certainty of the evidence of differences between treatments was very low. We noted no evidence of any differences in HRQoL at 12 months, although estimates were imprecise. We found that arthroplasty treatments seemed to have a greater likelihood of reducing unplanned return to theatre than internal fixation and non-operative treatment. We estimated that 4.3% of participants who received the reference treatment returned to theatre during the study follow-up. Compared to this treatment, we found low-certainty evidence that more participants returned to theatre if they were treated with a dynamic fixed angle plate (network estimate RR 4.63, 95% CI 2.94 to 7.30; from direct evidence from 1 study with 190 participants, and indirect evidence). We found very low-certainty evidence that more participants returned to theatre when treated with pins (RR 4.16, 95% CI 2.53 to 6.84; only from indirect evidence), screws (network estimate RR 5.04, 95% CI 3.25 to 7.82; from direct evidence from 2 studies with 278 participants, and indirect evidence), and non-operative treatment (RR 5.41, 95% CI 1.80 to 16.26; only from indirect evidence). There was very low-certainty evidence of a tendency for an increased risk of unplanned return to theatre for all of the arthroplasty treatments, and in particular for THA, compared with cemented modern unipolar HA, with little evidence to suggest the size of this difference varied strongly between the arthroplasty treatments.

AUTHORS' CONCLUSIONS

There was considerable variability in the ranking of each treatment such that there was no one outstanding, or subset of outstanding, superior treatments. However, cemented modern arthroplasties tended to more often yield better outcomes than alternative treatments and may be a more successful approach than internal fixation. There is no evidence of a difference between THA (single articulation) and cemented modern unipolar HA in the outcomes measured in this review. THA may be an appropriate treatment for a subset of people with intracapsular fracture but we have not explored this further.

Long-term results after over 17 years - Intramedullary gliding nail as treatment for traumatic femoral neck fractures

Background

For the treatment of femoral neck fracture there are many different implants present on the market. Postoperative complications still exist.

Patients and methods

The aim of this retrospective study was to evaluate the Gliding Nail in patients with medial femoral neck fractures and their long-term complications.

Results

In a collective of 113 patients we had all together 21 major complications in 2018.12/113 minor complications in 2008 and all together 13/78 in 2018 has been detected.

Conclusions

The Gliding Nail as an intramedullary implant shows a high load-bearing capacity with a high rotational stability and a low cut-out rate.

Treatment of Traumatic Femoral Neck Fractures with an Intramedullary Nail in Osteoporotic Bones

PURPOSE

Sufficient anchoring of intramedullary osteosynthesis in the femoral head in a femoral neck fracture is a challenge with increasing age of the patients and decreasing bone quality. For older patients with inferior bone quality, it has not been investigated whether the application of an intramedullary force carrier, as a minimally invasive and rapid intervention, can provide a considerable benefit and reduce the postoperative complication and lethality rate. This retrospective study aimed to investigate the stability and functionality after the acute treatment of a femoral neck fracture in osteoporotic bone using an intramedullary force carrier even with higher grade fracture types.

MATERIAL AND METHODS

The retrospective analysis was based on a collective of 82 patients over 60 years of age with a femoral neck fracture treated with a gliding nail in our centre between 1999 and 2006.

RESULTS

The average time to follow-up was 69.05 months (median 71.0; minimum 27.0-maximum 108.0). Female patients made up more than two-thirds of the patient collective at 63 of the 82 patients (76.83%). The average age of the patients was 77.76 years (median 78.00; range 60.00-93.00).In 66 patients (80.49%), the implantation showed good results and no complications or further treatments. 24/82 patients of our collective had died in our re-evaluation. In no case, a pseudarthrosis or severe impaction with neck shortening occurred (loss of offset).11/82 patients had femoral head necrosis which led to total hip replacement in 8 cases, a hemiarthroplasty in 2 cases and in 1 case a remaining Girdlestone situation because of a deep infection. Another five patients also had to undergo a total hip replacement because of a central perforation of the blade in one case, breakout of the blade after another fall in another two cases and a lateral dislocation of the blade in two cases.

CONCLUSION

The use of an intramedullary force carrier in the osteoporotic bone can mean distinct advantages for the selected patient as a minimally invasive and rapid surgical method compared to extensive surgery, even in the case of severe injuries. However, the advantages and disadvantages for the patient should be considered critically.

Internal fixation implants for intracapsular hip fractures in older adults

BACKGROUND

Hip fractures are a major healthcare problem, presenting a huge challenge and burden to patients, healthcare systems and society. The increased proportion of older adults in the world population means that the absolute number of hip fractures is rising rapidly across the globe. The majority of hip fractures are treated surgically. This review evaluates evidence for types of internal fixation implants used in joint-preserving surgery for intracapsular hip fractures.

OBJECTIVES

To determine the relative effects (benefits and harms) of different implants for the internal fixation of intracapsular hip fractures in older adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Web of Science, Cochrane Database of Systematic Reviews, Epistemonikos, Proquest Dissertations and Theses, and National Technical Information Service in July 2020. We also searched clinical trials databases, conference proceedings, reference lists of retrieved articles and conducted backward-citation searches.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs comparing implants used for internal fixation of fragility intracapsular proximal femoral fractures in older adults. Types of implants were smooth pins (these include pins with fold-out hooks), screws, or fixed angle plates. We excluded studies in which all or most fractures were caused by specific pathologies other than osteoporosis or were the result of a high energy trauma.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion. One review author extracted data and assessed risk of bias which was checked by a second review author. We collected data for seven outcomes: activities of daily living (ADL), delirium, functional status, health-related quality of life (HRQoL), mobility, mortality (reported within four months of surgery as early mortality, and at 12 months since surgery), and unplanned return to theatre for treating a complication resulting directly or indirectly from the primary procedure (such as deep infection or non-union). We assessed the certainty of the evidence for these outcomes using GRADE.

MAIN RESULTS

We included 38 studies (32 RCTs, six quasi-RCTs) with 8585 participants with 8590 intracapsular fractures. The mean ages of participants in the studies ranged from 60 to 84 years; 73% were women, and 38% of fractures were undisplaced. We report here the findings of the four main comparisons, which were between different categories of implants. We downgraded the certainty of the outcomes for imprecision (when data were available from insufficient numbers of participants or the confidence interval (CI) was wide), study limitations (e.g. high or unclear risks of bias), and inconsistency (when we noted substantial levels of statistical heterogeneity). Smooth pins versus fixed angle plate (four studies, 1313 participants) We found very low-certainty evidence of little or no difference between the two implant types in independent mobility with no more than one walking stick (1 study, 112 participants), early mortality (1 study, 383 participants), mortality at 12 months (2 studies, 661 participants), and unplanned return to theatre (3 studies, 736 participants). No studies reported on ADL, delirium, functional status, or HRQoL. Screws versus fixed angle plates (11 studies, 2471 participants) We found low-certainty evidence of no clinically important differences between the two implant types in functional status using WOMAC (MD -3.18, 95% CI -6.35 to -0.01; 2 studies, 498 participants; range of scores from 0 to 96, lower values indicate better function), and HRQoL using EQ-5D (MD 0.03, 95% CI 0.00 to 0.06; 2 studies, 521 participants; range -0.654 (worst), 0 (dead), 1 (best)). We also found low-certainty evidence showing little or no difference between the two implant types in mortality at 12 months (RR 1.04, 95% CI 0.83 to 1.31; 7 studies, 1690 participants), and unplanned return to theatre (RR 1.10, 95% CI 0.95 to 1.26; 11 studies, 2321 participants). We found very low-certainty evidence of little or no difference between the two implant types in independent mobility (1 study, 70 participants), and early mortality (3 studies, 467 participants). No studies reported on ADL or delirium. Screws versus smooth pins (seven studies, 1119 participants) We found low-certainty evidence of no or little difference between the two implant types in mortality at 12 months (RR 1.07, 95% CI 0.85 to 1.35; 6 studies, 1005 participants; low-certainty evidence). We found very low-certainty evidence of little or no difference between the two implant types in early mortality (3 studies, 584 participants) and unplanned return to theatre (5 studies, 862 participants). No studies reported on ADL, delirium, functional status, HRQoL, or mobility. Screws or smooth pins versus fixed angle plates (15 studies, 3784 participants) In this comparison, we combined data from the first two comparison groups. We found low-certainty evidence of no or little difference between the two groups of implants in mortality at 12 months (RR 1.04, 95% CI.083 to 1.31; 7 studies, 1690 participants) and unplanned return to theatre (RR 1.02, 95% CI 0.88 to 1.18; 14 studies, 3057 participants). We found very low-certainty evidence of little or no difference between the two groups of implants in independent mobility (2 studies, 182 participants), and early mortality (4 studies, 850 participants). We found no additional evidence to support the findings for functional status or HRQoL as reported in 'Screws versus fixed angle plates'. No studies reported ADL or delirium.

AUTHORS' CONCLUSIONS

There is low-certainty evidence that there may be little or no difference between screws and fixed angle plates in functional status, HRQoL, mortality at 12 months, or unplanned return to theatre; and between screws and pins in mortality at 12 months. The limited and very low-certainty evidence for the outcomes for which data were available for the smooth pins versus fixed angle plates comparison, as well as the other outcomes for which data were available for the screws and fixed angle plates, and screws and pins comparisons means we have very little confidence in the estimates of effect for these outcomes. Additional RCTs would increase the certainty of the evidence. We encourage such studies to report outcomes consistent with the core outcome set for hip fracture, including long-term quality of life indicators such as ADL and mobility.

Dynamic locking plate vs. cannulated cancellous screw for displaced intracapsular hip fracture: A comparative study

Introduction

There is no consensus regarding the optimal device for displaced intracapsular hip fractures. This retrospective study compared two techniques (1) cannulated cancellous screw (CCS), and (2) Targon Femoral Neck (TFN) plate.

Materials and methods

Data regarding gender, operational data, complications, pain, Quality of life and function scores were retrieved.

Results

103 patients were included, 42 were treated using CCS, compared to 61 treated using TFN. Operative time shorter for CCS (p = 0.019). Complication rates were not different (p > 0.05).

Conclusion

As CCS method take shorter operating time and reduced costs, CCS should be used for the treatment of displaced ICHF.

Reversed Z-effect and Z-effect phenomena in femoral neck fracture treated with a dynamic locking plate fixation: Case report

The aim of this case report is to present an unusual mechanism of failure of a dynamic locking plate (DLP), previously reported in dual lag screw proximal femoral nails. A 78-year-old female patient experienced a displaced right femoral neck fracture (FNF) which was managed with DLP. At the postoperative sixth- week appointment, her hip radiographs showed that two of three telescoping screws had slid within the telescrew barrel, and one screw was fully extended and cutting through the femoral head. At the third-month checkup, radiographs revealed an unhealed FNF and 12 mm sliding on all three telescoping screws. At the final 11th-month follow-up, two screws were completely collapsed and the previously nonpenetrating screw was partially extended and cutting through the femoral head. Femoral neck shortening and femoral neck nonunion were noticed as well. In conclusion, the postoperative course of the case supports the hypothesis of a specific pattern of DLP failure resembling reversed Z- and Z-effects found in dual lag screw proximal femoral nails.

Biomechanical evaluation of locked plating fixation for unstable femoral neck fractures

Aims

Evaluate if treating an unstable femoral neck fracture with a locking plate and spring-loaded telescoping screw system would improve construct stability compared to gold standard treatment methods.

Methods

A 31B2 Pauwels' type III osteotomy with additional posterior wedge was cut into 30 fresh-frozen femur cadavers implanted with either: three cannulated screws in an inverted triangle configuration (CS), a sliding hip screw and anti-rotation screw (SHS), or a locking plate system with spring-loaded telescoping screws (LP). Dynamic cyclic compressive testing representative of walking with increasing weight-bearing was applied until failure was observed. Loss of fracture reduction was recorded using a high-resolution optical motion tracking system.

Results

LP constructs demonstrated the highest mean values for initial stiffness and failure load. LP and SHS constructs survived on mean over 50% more cycles and to loads 450 N higher than CS. During the early stages of cyclic loading, mean varus collapse of the femoral head was 0.5° (SD 0.8°) for LP, 0.7° (SD 0.7°) for SHS, and 1.9° (SD 2.3°) for CS (p = 0.071). At 30,000 cycles (1,050 N) mean femoral neck shortening was 1.8 mm (SD 1.9) for LP, 2.0 mm (SD 0.9) for SHS, and 3.2 mm (SD 2.5) for CS (p = 0.262). Mean leg shortening at construct failure was 4.9 mm (SD 2.7) for LP, 8.9 mm (SD 3.2) for SHS, and 7.0 mm (SD 4.3) for CS (p = 0.046).

Conclusion

Use of the LP system provided similar (hip screw) or better (cannulated screws) biomechanical performance as the current gold standard methods suggesting that the LP system could be a promising alternative for the treatment of unstable fractures of the femoral neck.Cite this article: Bone Joint Res 2020;9(6):314-321.

Efficiency of an implant: new criterion of objective assessment of implants for osteosynthesis of femoral neck fracture

PURPOSE

In line with several designs for osteosynthesis of femoral neck fracture (FNF), their effectiveness is still estimated by the results of biomechanical and clinical trials, finite element method (FE). But surgeons require the criteria which would define their properties in advance and allow improve the results of treatment.

METHODS

When new implant (NI) is being designed, we developed such criterion - index efficiency of an implant (IEI) - and performed mathematical comparative researches of properties of NI with the known designs. We analyzed the results of comparative clinical trials on treatment of FNF with various implants considering their IEI.

RESULTS

Analysis showed that results of comparative clinical trials with the use of various implants for osteosynthesis FNF completely correlated to their IEI; IEI of the NI two to three times exceeds IEI of all known designs, and the destruction percentage of a bone tissue is two to three times less when it is applied.

CONCLUSION

The offered IEI can be used for designing new implants and allows improving the results of treatment of patients with FNF by optimizing the choice of implant for osteosynthesis.

[Research progress in treatment of femoral neck fracture in the elderly]

OBJECTIVE

To introduce the research progress of conservative treatment, internal fixation, hip arthroplasty, and multidisciplinary team (MDT) modes in the treatment of femoral neck fracture in the elderly.

METHODS

By consulting domestic and foreign literature in recent years, the characteristics and application of various treatment methods and new treatment modes for femoral neck fracture in the elderly were summarized and analyzed.

RESULTS

The elderly non-displaced femoral neck fracture should be treated surgically, and conservative treatment has a high risk of secondary displacement. The displaced fracture should be operated as soon as possible. There is no difference in long-term functional outcome between hemiarthroplasty and total hip arthroplasty. Hemiarthroplasty has less intraoperative blood loss, shorter operation time, and is suitable for the elderly patients with poor basic condition. Total hip arthroplasty is suitable for the elderly patients with better basic condition and higher demand of life quality. MDT can effectively reduce preoperative waiting time and length of stay, reduce the incidence of medical complications, improve the nutritional status of patients, and reduce the mortality of patients.

CONCLUSION

Significant results have been achieved in the treatment of femoral neck fractures in the elderly by methods such as internal fixation, hip arthroplasty, and MDT.

Femoral Neck Fractures in Young Patients: State of the Art

Femoral neck fractures in young patients are uncommon but are often associated with surgical challenges and complications. The quality of reduction, more than time to surgery, has the most impact on optimizing outcomes and function. There is no consensus in the best fixation construct for these fractures. Neck shortening and varus collapse are the most common challenges of current fixation options. Use of newer implants is being reported with cautious optimism, and further studies are needed. LEVEL OF EVIDENCE:: Therapeutic Level V.

Biomechanics of Femoral Neck Fractures and Implications for Fixation

Fractures of the femoral neck can occur in young healthy individuals due to high loads occurring during motor vehicle accidents, impacts, or falls. Failure forces are lower if impacts occur sideways onto the greater trochanter as compared with vertical loading of the hip. Bone density, bone geometry, and thickness of cortical bone at the femoral neck contribute to its mechanical strength. Femoral neck fractures in young adults require accurate reduction and stable internal fixation. The available techniques for fracture fixation at the femoral neck (cannulated screws, hip screw systems, proximal femur plates, and cephallomedullary nails) are reviewed with respect to their competence to provide biomechanical stability. Mechanically unstable fractures require a load-bearing implant, such as hip screws, with antirotational screws or intramedullary nails. Subcapital or transcervical fracture patterns and noncomminuted fractures enable load sharing and can be securely fixed with cannulated screws or solitary hip screw systems without compromising fixation stability.

Technologies for Young Femoral Neck Fracture Fixation

Fixation of young femoral neck fractures represents a challenge in the field of orthopaedic trauma surgery. Conventional methods, including cannulated screw and sliding hip screw constructs, have been studied and found to have similar results with regards to patient outcomes, which has made choosing an optimum fixation strategy difficult. In all of these cases, quality of reduction has been shown to be the most important factor when it comes to creating a favorable environment for fracture healing. Some of these patients, however, continue to have negative sequelae including nonunion, avascular necrosis, femoral head collapse, and poor hip function as a result. In this article, we review the 2 most commonly used constructs and present 2 novel fixation constructs for the fixation of femoral neck fractures in physiologically young patients, including the Smith & Nephew Conquest system and the Aesculap Targon system. We outline techniques for usage of these systems and proposed advantages to these systems compared with conventional fixation methods. We also discuss the results of previously published studies regarding conventional fixation methods and compare with some limited studies that have been published on these newer technologies.

Is dynamic locking plate superior than other implants for intracapsular hip fracture: A meta-analysis

BACKGROUND

We studied the safety and efficacy of dynamic locking plate vs. other implants (cannulated cancellous screws [CCS] or sliding hip screw [SHS]) in patients undergoing intracapsular hip fracture (ICHF).

METHODS

We searched Pubmed, Embase, Web of Science, Cochrane library and Google database from inception to March 25, 2018. We selected any studies comparing dynamic locking plate for treatment ICHF. Non-union rate, osteonecrosis rate, cutout rate, revision rate, the replacement rate, and Harris hip scores were the outcomes. Stata 12.0 was used for meta-analysis.

RESULTS

Four studies involving 419 patients (143 patients in the dynamic locking plate group and 276 patients in the other implants group) were finally included. Compared with CCS or SHS, dynamic locking plate was associated with a reduction of nonunion rate, revision rate, replacement rate (P <.05). Furthermore, dynamic locking plate was also associated with an increase of the Harris hip scores (P <.05). There was no significant difference between the osteonecrosis rate and cutout rate (P >.05).

CONCLUSIONS

Current meta-analysis revealed that dynamic locking plate has a benefit role in improving postoperative clinical outcome than CCS or SHS in ICHF patients. Further high quality and large-scale randomized controlled trials (RCTs) are needed to further identify the efficacy of dynamic locking plate for ICHF.

Increased torsional stability by a novel femoral neck locking plate. The role of plate design and pin configuration in a synthetic bone block model

BACKGROUND

In undisplaced femoral neck fractures, internal fixation remains the main treatment, with mechanical failure as a frequent complication. As torsional stable fixation promotes femoral neck fracture healing, the Hansson Pinloc® System with a plate interlocking pins, was developed from the original hook pins. Since its effect on torsional stability is undocumented, the novel implant was compared with the original configurations.

METHODS

Forty-two proximal femur models custom made of two blocks of polyurethane foam were tested. The medial block simulated the cancellous head, while the lateral was laminated with a glass fiber filled epoxy sheet simulating trochanteric cortical bone. Two hollow metal cylinders with a circumferential ball bearing in between mimicked the neck, with a perpendicular fracture in the middle. Fractures were fixated by two or three independent pins or by five configurations involving the interlocking plate (two pins with an optional peg in a small plate, or three pins in a small, medium or large plate). Six torsional tests were performed on each configuration to calculate torsional stiffness, torque at failure and failure energy.

FINDINGS

The novel configurations improved parameters up to an average of 12.0 (stiffness), 19.3 (torque) and 19.9 (energy) times higher than the original two pins (P < 0.001). The plate, its size and its triangular configuration improved all parameters (P = 0.03), the plate being most effective, also preventing permanent failure (P < 0.001).

INTERPRETATION

The novel plate design with its pin configuration enhanced torsional stability. To reveal clinical relevance a clinical study is planned.

Is dynamic locking plate(Targon FN) a better choice for treating of intracapsular hip fracture? A meta-analysis

PURPOSE

The aim of this study was to assess the outcomes of dynamic locking plate (Targon FN) and other alternative implant (cannulated cancellous screws or sliding hip screw) for treating of intracapsular hip fracture.

METHODS

Relevant clinical trials on the dynamic locking plate and alternative implant treatment for intracapsular hip fracture were retrieved through searching the databases, PubMed, Embase and the Cochrane Central Register of Controlled Trials up to August 2017. Studies that investigated the comparing effectiveness or complications between both groups and provided sufficient data of interest were included in this meta-analysis.

RESULTS

Four studies involving 385 intracapsular hip fractures were included. The differences in nonunion [odds ratio (OR) 0.16,95% confidence interval (CI) 0.05-0.49], revision (OR 0.56, 95%CI 0.32-0.96) and replacement rate (OR 0.26, 95%CI 0.10-0.69) were statistically significant between dynamic locking plate and alternative implant group. There was no statistically significant difference in osteonecrosis (OR1.73, 95%CI0.59-5.02), cut-out (OR0.89,95%CI0.23-3.46)and non orthopaedics complication rate (OR0.73, 95% CI 0.38-1.41).

CONCLUSIONS

The available evidence indicate that dynamic locking plate offers a superior outcome in comparison with alternative implants and reduces the nonunion, revision and replacement rates for treating intracapsular hip fractures, but does not affect the osteonecrosis, cutout and non-orthopadeics complication rate. Decisions should be made in accordance with specific conditions for clinical application.

The outcome of intracapsular hip fracture fixation using the Targon Femoral Neck (TFN) locking plate system or cannulated cancellous screws: A comparative study involving 2004 patients

AIM

This study compares the outcome of intracapsular hip fracture fixation using the Targon Femoral Neck (TFN) locking plate system with the standard fixation using cannulated cancellous screws (CCS).

PATIENTS AND METHOD

Analyses of a prospectively collected data of all patients treated for intracapsular hip fractures using the TFN system and CCS at our department over a period of 28 years. Baseline characteristics and specific outcome measures where compared. The primary outcome measure was fracture revision during the 1st year. Secondary outcome measures were fracture complications, any revision surgery, mortality and mobility status at one year after surgery.

RESULTS

A total of 2004 fractures were included, a third (n=725, 36.2%) were treated using the TFN system. There were higher rates of non-union (19.5% vs 9.5%) and revision surgery (19% vs 9%) during the first year in the CCS cohort. Revision surgery was also higher in the same group during the whole of the follow-up period (22.2% vs 14.9%). The first year's mortality rate was higher in the CCS cohort (21.1% vs 17.5%) but the reduction in mobility and mobility scores was the same in both cohorts.

CONCLUSION

This study includes the largest cohort of cases treated for intracapsular hip fractures using the TFN system. It demonstrated that the TFN system was associated with lower rates of non-union, revisions and re-operations for any cause.

Screw-blade fixation systems in Pauwels three femoral neck fractures: a biomechanical evaluation

OBJECTIVES

To reduce mechanical complications after osteosynthesis of femoral neck fractures, improved fixation techniques have been developed including blade or screw-anchor devices. This biomechanical study compares different fixation systems used for treatment of unstable femoral neck fractures with evaluation of failure mode, load to failure, stiffness, femoral head rotation, femoral neck shortening and femoral head migration.

METHODS

Standardized Pauwels type 3 fractures (AO/OTA 31-B2) with comminution were created in 18 biomechanical sawbones using a custom-made sawguide. Fractures were stabilized using either SHS-Screw, SHS-Blade or Rotationally Stable Screw-Anchor (RoSA). Femurs were positioned in 25 degrees adduction and ten degrees posterior flexion and were cyclically loaded with an axial sinusoidal loading pattern of 0.5 Hz, starting with 300 N, with an increase by 300 N every 2000 cycles until bone-implant failure occurred.

RESULTS

Mean failure load for the Screw-Anchor fixation (RoSA) was 5100 N (IQR 750 N), 3900 N (IQR 75 N) for SHS-Blade and 3000 N (IQR 675 N; p = 0.002) for SHS-Screw. For SHS-Screw and SHS-Blade we observed fracture displacement with consecutive fracture collapse as the main reason for failure, whereas RoSA mainly showed a cut-out under high loadings. Mean stiffness at 1800 N was 826 (IQR 431) N/mm for SHS-Screw, 1328 (IQR 441) N/mm for SHS-Blade and 1953 (IQR 617) N/mm for RoSA (p = 0.003). With a load of 1800 N (SHS-Screw 12° vs. SHS-Blade 7° vs. RoSA 2°; p = 0.003) and with 2700 N (24° vs. 15° vs. 3°; p = 0.002) the RoSA implants demonstrated a higher rotational stability and had the lowest femoral neck shortening (p = 0.002), compared with the SHS groups. At the 2700 N load point, RoSA systems showed a lower axial (p = 0.019) and cranial (p = 0.031) femoral head migration compared to the SHS-Screw.

CONCLUSIONS

In our study, the new Screw-Anchor fixation (RoSA) was superior to the comparable SHS implants regarding rotational stability and femoral neck shortening. Failure load, stiffness, femoral head migration, and resistance to fracture displacement were in RoSA implants higher than in SHS-Screws, but without significance in comparison to SHS-Blades.

Anchorage strategies in geriatric hip fracture management

There is an enormous humanitarian and socioeconomic need to improve the quality and effectiveness of care for patients with hip fracture. To reduce mechanical complications in the osteosynthesis of proximal femoral fractures, improved fixation techniques have been developed including blade or screw-anchor devices, locked minimally invasive or cement augmentation strategies. However, despite numerous innovations and advances regarding implant design and surgical techniques, systemic and mechanical complication rates remain high. Treatment success depends on secure implant fixation in often-osteoporotic bone as well as on patient-specific factors (fracture stability, bone quality, comorbidity, and gender) and surgeon-related factors (experience, correct reduction, and optimal screw placement in the head/neck fragment). For fracture fixation, the anchorage of the lag screw within the femoral head plays a crucial role depending on the implant's design. Meta-analyses and randomized controlled studies demonstrate that there is a strong trend towards arthroplasty treating geriatric femoral neck fractures. However, for young adults as well as older patients with less compromised bone quality, or in undisplaced fractures, head-preserving therapy is preferred as it is less invasive and associated with good functional results. This review summarizes the evidence for the internal fixation of femoral neck fractures and trochanteric femoral fractures in elderly patients. In addition, biomechanical considerations regarding implant anchorage in the femoral head including rotation, migration, and femoral neck shortening are made. Finally, cement augmentation strategies for hip fracture implants are evaluated critically.

Clinical results of surgical treatment for femoral neck fractures with the Targon® FN

84 cases (male 15 cases, female 69 cases) of intracapsular femoral neck fractures treated with the Targon^® FN (TFN) were available for review. Mean patient age was 74.0 years (range 36-100 years). 55 fractures were undisplaced whereas 29 were displaced. Mean follow-up term was 16.4 months. We surveyed patient mobility before injury and after operation as well as postoperative complications. On a four-stage mobility scale we found 3/55 patients with undisplaced fractures loosing mobility by more than one grade (5.5%), whereas 5/29 (17.2%) displayed this kind of functional decline after displaced fractures. Overall postoperative complication rate was 10.7% (9 cases). These complications included nonunion (1 case), avascular necrosis (7 cases) and peri-implant fracture (1case). Internal fixation with the TFN seems to have an acceptable complication rate in both undisplaced and displaced fractures compared to other recent studies.

Augmentation by cerclage wire improves fixation of vertical shear femoral neck fractures-A biomechanical analysis

BACKGROUND

Femoral neck fractures in young individuals are typically vertical shear fractures. These injuries are difficult to stabilize due to a significant varus displacement force across the hip with weight bearing. The purpose of this study was to evaluate the biomechanical stability offered by the addition of an augmented wire to conventional inverted triangle triple screw fixation for stabilizing vertical shear femoral neck fracture.

METHODS

Sixteen medium 4th-generation synthetic composite femurs (Sawbones Pacific Research Laboratories, Vashon, WA) were divided into two groups. Vertical osteotomy was performed to mimic Pauwels III femoral neck fracture. Group A (n=8) was fixed with three parallel 6.5-mm cannulated screws (Stryker) with washer in inverted triangle configuration. In group B (n=8), all the screws were set using methods identical to group A, with the addition of the cerclage wire. Both groups were tested with nondestructive axial compression test at 7 and 25° of valgus stress, respectively. Then axial cyclic loading test with 1000N was applied for 1000 cycles, and interfragmentary displacement was measured with Fastrak magnetic tracking system (Polhemus, Colchester, VT, USA). Finally, destructive axial compression test was conducted at 7°of valgus stress.

RESULTS

Axial stiffness showed that group B had a 66% increase (879N/mm vs. 1461N/mm, P<0.01) at 7° valgus and a 46% increase (1611N/mm vs. 2349N/mm, P<0.01) at 25° valgus in comparison with group A. Interfragmentary fracture displacement after cyclic loading was significantly less for group B compared with group A (0.34 vs 0.13mm, P=0.0016). For axial failure load, there was 42% increase in group B compared with group A (2602N/mm vs. 3686N/mm, P=0.0023).

CONCLUSIONS

Our study demonstrates that the addition of a cerclage wire to inverted triangle triple screws provides substantial improvement in mechanical performance regarding fixation of vertically oriented femoral neck fractures when compared with the conventional construct. Our study provides support from a mechanical analysis perspective for the reported clinical usefulness of the cerclage wire.

[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.

Fixation of displaced femoral neck fractures in young adults: Fixed-angle devices or Pauwel screws?

BACKGROUND

We sought to compare the incidence of complications after fixation of displaced femoral neck fractures in young adults treated with fixed-angle devices versus multiple cancellous screws and a trochanteric lag screw (Pauwel screw).

METHODS

We conducted a retrospective cohort study at a level I trauma centre. Sixty-two skeletally mature patients (age range, 16-60 years) with displaced femoral neck fractures were included in the study. Forty-seven were treated with a fixed-angle device (sliding hip plate with screw or helical blade) and 15 with multiple cancellous screws placed in a Pauwel configuration. The main outcome measure was postoperative complication of osteonecrosis or nonunion treated with a surgical procedure.

RESULTS

Significantly fewer failures occurred in the fixed-angle group (21%) than in the screws group (60%) (p=0.008). Osteonecrosis was rare in the fixed-angle group, occurring in 2% of cases versus 33% of cases in the screws group (p=0.002). Consistent with previous studies, good to excellent reductions were associated with a failure rate of 25% and fair to poor reductions were associated with a failure rate of 55% (p=0.07). The best-case scenario of a good to excellent reduction stabilised with a fixed-angle device yielded a success rate of 85%.

CONCLUSION

In young patients with displaced high-energy femoral neck fractures, fixed-angle devices resulted in fewer treatment failures than did Pauwel screws.

Failure of fracture fixation in osteoporotic bone

This manuscript will provide an overview of how the age and osteoporosis related changes in mechanical properties of bone affect the stability of osteosynthesis constructs, both from a mechanical as well as from a clinical perspective. The manuscript will also address some of the principles of fracture fixation for osteoporotic fractures and discuss applications of osteoporotic fracture fixation at sites typically affected by fragility fractures, namely the distal radius, the proximal humerus, the femur and the spine. The primary aim of operative treatment in elderly individuals is the avoidance of immobilization of the patient. In selected cases conservative treatment might be required. Generally, choice of treatment should be individualized and based on the evaluation of patient-specific, fracture-specific and surgeon-specific aspects. The orthopaedic surgeon plays an essential role in enabling functional recovery by providing good surgery but a multidisciplinary approach is essential in order to support the patient to regain his/her quality of life after fragility fracture. Overall, the therapy of fractures in osteoporotic bone in the elderly requires a multidisciplinary therapeutic acute care concept including treatment of co-morbidities and correct choice of timing, and technique of the operative intervention.

[Joint-preserving treatment of medial femoral neck fractures with an angular stable implant]

OBJECTIVE

Operative stabilization is recommended even for non-displaced or only slightly displaced femoral neck fractures. In addition to the known osteosynthetic procedures, an angular stabile implant system (Targon® FN) has been established since 2006 for treatment of such fractures.

INDICATIONS

Displaced femoral neck fractures (Garden III and IV) and non-displaced fractures (Garden I and II).

CONTRAINDICATIONS

Fractures close to the hip joint, which are not classified as typical medial femoral neck fractures and patients with advanced osteoarthritis of the hip who would profit from an endoprosthetic procedure.

SURGICAL TECHNIQUE

The operative procedure is shown after fracture reposition and central positioning of the guide wire as a standard course.

POSTOPERATIVE MANAGEMENT

Early postoperative mobilization under guidance of a physiotherapist. Initially, partial weight bearing only in selected cases with severe displacement.

RESULTS

In our patients collective the Targon® FN has been implanted in over 100 cases. Revision indications and secondary endoprosthesis were documented in only 9 % of the cases. This angular stable screw osteosynthesis system is a safe procedure to achieve patient mobility if the indications are adhered to and implantation is correctly carried out.

[Femoral neck fracture]

The incidence of femoral neck fractures increases exponentially with rising age. Young patients are rarely affected but when they are it is mostly due to high energy accidents, whereas older patients suffer from femoral neck fractures by low energy trauma due to osteoporotic changes of the bone mineral density. Treatment options have not essentially changed over the last few years. Non-operative treatment may be a choice in non-dislocated and impacted fractures. Due to the high risk of secondary fracture displacement prophylactic screw osteosynthesis is recommended even in Garden type I fractures. Osteosynthetic fracture stabilization with cannulated screws or angle stable sliding screws, is usually applied in non-displaced fractures and fractures in younger patients. Older patients need rapid mobilization after surgery; therefore, total hip arthroplasty and hemiarthroplasty are commonly used with a low incidence of secondary complications. In addition to sufficient operative treatment a guideline conform osteoprosis therapy should be initiated for the prophylaxis of further fractures and patients should undertake a suitable rehabilitation.

Enhancement of hip fracture healing in the elderly: Evidence deriving from a pilot randomized trial

Enhancement of healing of osteoporotic fractures remains a significant objective of contemporary clinical care. Aiming to produce preliminary clinical evidence on the effect of antiosteoporotic drugs on the process of fragility fracture healing, a pilot prospective randomized assessor-blinded trial was performed. The tested hypothesis was that it is possible to accelerate the healing of hip fractures in the presence of osteoporosis with the administration of therapeutic agents. However, significant difficulties of recruitment and completion of follow up did not allow the researchers to produce the preliminary evidence testing the study hypothesis, highlighting the challenges that contemporary clinical investigators face when conducting studies focusing on elderly patients, with high proportion of coinciding factors affecting patients' eligibility, compliance, and overall outcome. Nevertheless, the significance of enhancing bone healing in this specific patient population, dictates further clinical efforts and future well designed and funded trials of adequate power and level of evidence are desirable to allow the effective and safer management of the consequences of the modern epidemic of osteoporosis.

Plating of femoral neck fractures: when and how?

Intracapsular femoral neck fractures are common in the elderly population after a simple fall. However, femoral neck fractures in the physiologically young are less common. Regardless, femoral neck fractures can be a source of significant morbidity and mortality if not treated correctly. Multiple management strategies have been described. The decision for the ideal treatment involves careful consideration of the patient's age, activity, and medical comorbidities. Plating techniques of femoral neck fractures continue to evolve. The authors describe the current indications and plating options for the treatment of femoral neck fractures.

Femoral neck fractures: current management

Femoral neck fractures are a commonly encountered injury in orthopaedic practice and result in significant morbidity and mortality. It is essential that surgeons are able to recognize specific fracture patterns and patient characteristics that indicate the use of particular implants and methods to effectively manage these injuries. Use of the Garden and Pauwels classification systems has remained the practical mainstay of femoral neck fracture characterization that help dictate appropriate treatment. Operative options include in situ fixation, closed or open reduction and internal fixation, hemiarthroplasty, and total hip arthroplasty. Recent reports demonstrate diversity among orthopaedic surgeons in regard to the optimal treatment of femoral neck fractures and changing trends in management. The present discussion focuses on the current indications and methods for femoral neck fracture management to provide direction with respect to appropriate and effective care of these injuries.

Functional recovery of elderly patients with surgically-treated intertrochanteric fractures: preliminary results of a randomised trial comparing the dynamic hip screw and proximal femoral nail techniques

INTRODUCTION

Intertrochanteric fractures of the femur are prevalent in the elderly, and leave patients with functional restrictions after surgical treatment. The aim of this study was to compare the functional recovery at 1-year follow-up of elderly patients with intertrochanteric fractures treated surgically with the dynamic hip screw (DHS) or proximal femoral nail (PFN) fixation techniques.

MATERIAL AND METHODS

This prospective, randomised, blinded trial included patients aged over 65 years with intertrochanteric fractures classified as AO group 31.A1 or 31.A2. The patients were allocated into one of two treatment groups: one treated with DHS and the other with PFN. Data on functional recovery were obtained using the Functional Recovery Score developed by Zuckerman for elderly patients with hip fracture. Variables were described as means and standard deviations, and the non-parametric Kolmogorov-Smirnov test was used to verify the normality of data distribution. Non-normally distributed variables were compared using the non-parametric Friedman and Mann-Whitney U tests. Data processing and analysis were carried out in SPSS 10.0. Results were deemed significant at the 5% level (p ≤ 0.05).

RESULTS

There were no significant between-group differences in age (p=0.152), sex (p=0.363), or American Society of Anaesthesiologists (ASA) score (p=0.579). Functional recovery scores in the DHS group at 3 and 6 months after surgery were significantly reduced from preoperative baseline scores (p=0.007) compared with in the PFN group. However, there were no statistically significant differences between the two groups in functional recovery scores at baseline (p=0.346) or at 3 months (p=0.880), 6 months (p=0.699), and 12 months (p=0.468) after surgery. There was no between-group difference in mortality (p=0.140).

CONCLUSION

At 1-year follow-up, functional recovery scores were similar in elderly patients treated with the DHS and PFN techniques. However, DHS-treated patients exhibited significant loss of function in the first 6 months after surgery, which did not occur in the PFN-treated group.