Internal fixation of garden I and II femoral neck fractures: posterior tilt did not influence the reoperation rate in 382 consecutive hips followed for a minimum of 5 years

The dynamic locking blade plate: seven-year follow-up results of 389 patients with a femoral neck fracture

PURPOSE

This study aimed to investigate the long-term outcomes of patients with a femoral neck fracture (FNF), treated with the Dynamic Locking Blade Plate (DLBP).

METHODS

Retrospective analysis of prospectively collected data of a multicentre cohort of patients with FNFs was conducted, regarding the long-term incidence of revision surgery after DLBP. Implant failure was evaluated using Kaplan-Meier and Cox regression analysis. Secondary outcomes were the indication for revision surgery, complications, time to revision surgery, rate of elective removal of the implant, potential predictors for revision surgery and mortality.

RESULTS

Median follow-up of 389 included patients was 98 months; 20.6% underwent revision surgery; 28.8% after treatment of a displaced FNF (dFNF) and 10.0% with a undisplaced FNF (uFNF). 5.7% (n = 22) of the patients had operation related complications and 32.9% (n = 128) deceased during follow-up. Median time to revision surgery was 13 (dFNF) and 18 months (uFNF). 15.7% of the DLBPs were electively removed. In the multivariate Cox regression analysis, female gender (hazard ratio 2.1, 95% CI 1.2-3.7) and a TAD > 25 mm (hazard ratio 2.9, 95% CI 1.7-5) were significant predictors for revision surgery in patients with dFNF.

CONCLUSION

This study is the first long-term follow-up study on the outcome of the DLBP. The DLBP demonstrated positive long-term results in the treatment of FNF.

Sagittal Angulation and the Treatment of Geriatric Femoral Neck Fractures: Time to Update our Classification Systems

OBJECTIVES

Inconsistent outcomes have been reported for percutaneous fixation of Garden I/II femoral neck fractures in geriatric patients. It was hypothesized that accounting for variable follow-up would better estimate the failure rate of percutaneous fixation with and without significant sagittal angulation.

METHODS

DESIGN

Retrospective.

SETTING

Single academic healthcare system.

PATIENT SELECTION CRITERIA

Patients ≥50 years of age treated with percutaneous screw fixation of Garden I/II (OTA/AO B1.1/B1.2) femoral neck fractures from 2010 to 2020 were identified. Pathologic fractures and open approaches were excluded.

OUTCOME MEASURES AND COMPARISONS

Sagittal angulation was measured using a previously described method. 11 Treatment failure was defined as early fixation failure (within 6 weeks), nonunion, and/or avascular necrosis. Potential associations between treatment failure and patient, injury, and treatment variables were assessed. Cox proportional hazard analysis accounted for variable follow-up when assessing for event-free survival.

RESULTS

Of the 240 fractures that met inclusion criteria, there were 20 treatment failures (8%) and 33 fractures with sagittal angulation ≥20 degrees on lateral radiographs (14%). Failure-free survival at 2 years was 91% for patients with <20 degrees of posterior angulation and 52% for patients with ≥20 degrees of posterior angulation ( P < 0.0001). The hazard ratio, which incorporates variable follow-up, for failure with ≥20 degrees of posterior angulation was 6.36 ( P < 0.0001). No other factors were associated with treatment failure.

CONCLUSIONS

Significant posterior angulation (≥20 degrees) of Garden I/II femoral neck fractures is associated with a high failure rate after screw fixation. The authors suggest characterizing fractures with ≥20 degrees of sagittal angulation as Garden III fractures to better support surgical decision making.

LEVEL OF EVIDENCE

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

Valgus-impacted subcapital neck of femur fractures: a systematic review, meta-analysis with cost analysis of fixation in-situ versus nonoperative management

BACKGROUND

The management of the valgus-impacted neck of femur fracture (AO/OTA 31-B1) remains contentious. The objective of this study was to determine whether operative intervention is cost-effective.

METHODS

We conducted a systematic review using electronic databases (Medline, Embase, Cochrane, Ebsco, Scholar) identifying studies published in the English language concerning valgus-impacted neck of femur fractures until June 2022. Additional studies were identified through hand searches of major orthopaedic journals, and bibliographies of major orthopaedic textbooks. MeSH terms (hip fracture and femoral neck fracture) and keywords (undisplaced, valgus-impacted, valgus, subcapital, Garden) connected by the Boolean operators "AND" and "OR" were used to identify studies. 2 reviewers independently extracted the data using standardised forms and recording spreadsheet. Methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-analysis of Statistics Assessment and Review Instrument. Meta-analysis was undertaken. Outcome measures were rate of displacement, avascular necrosis, non-union, mortality and requirement of further operative intervention. A cost utility analysis was then conducted to compare the 2 groups on the basis of the cost of initial treatment and the potential requirement of secondary intervention to hemiarthroplasty.

RESULTS

47 studies met the inclusion criteria. Meta-analysis data demonstrated a significant difference in the displacement rate of 22.8% and 2.8% between the nonoperative and internal fixation groups respectively (p = 0.05). The overall incidence of further operative intervention for each group was 23% and 10% respectively. There was no significant difference with respect to avascular necrosis, mortality or union rates. The cost utility analysis revealed nonoperative management to be approximately 60% more costly than initial internal fixation when the costs of subsequent surgery were included.

CONCLUSIONS

This meta-analysis of the existing literature concludes that whilst nonoperative management is possible for valgus impacted neck of femur fractures, it is associated with higher complication rates and greater expense than management by internal fixation.

Management of Garden-I and II Femoral Neck Fractures: Perspectives on Primary Arthroplasty

This review compares internal fixation versus arthroplasty in the treatment of nondisplaced femoral neck fractures (FNFs) calling attention to evolving areas of consensus that influence clinical decision-making. The Garden classification system, typically dichotomized into nondisplaced (types I and II) and displaced (types III and IV) fractures, has been used as a guide for surgical decision-making. Conventionally, treatment of nondisplaced FNF in the elderly has been with internal fixation, and treatment of a displaced FNF has been hemi-, or more recently total hip, arthroplasty. Studies over the last decade have raised concern over the appropriate treatment of nondisplaced FNFs due to high rates of reoperation of nondisplaced FNFs treated with internal fixation. Avascular necrosis (AVN), failure of internal fixation, secondary malunion, and pin/nail penetration through the femoral head have all been observed. Several studies have attributed fixation failure to a degree of femoral neck tilt ≥20°, either posteriorly or anteriorly as seen on the lateral X-ray. Because of these observations of fixation failures, the suggestion has been made that arthroplasty be used when the degree of posterior tilt exceeds a threshold of ≥20° tilt with the expectation of diminishing failure of fixation, decreasing the risk of reoperation and preserving function without increasing mortality rate. Frustrating additional analyses are uncertainties over the mechanisms of failure of internal fixation with ≥20° tilt and the persistently substantial 1-year mortality rate after FNF, which has not been influenced by fixation or replacement type. Due to the lack of consensus regarding the determination of the appropriate surgical intervention for nondisplaced FNFs, an improved algorithm for surgical decision-making for these fractures may prove useful.

What is the Fate of Undisplaced Femoral Neck Fractures Treated With Cannulated Screws?

BACKGROUND

We aimed to report implant survival in Garden type I and II femoral neck fractures treated with cannulated screws in elderly patients.

METHODS

We retrospectively studied 232 consecutive unilateral Garden I and II patients (232 fractures) treated with cannulated screws. Mean age was 81 years (range, 65 to 100), and a body mass index of 25 (range, 15.8 to 38.3). No between-group differences were found in demographic variables and/or baseline measurements (P > .05). Mean follow-up was 36 months (range, 1 to 171). Two observers measured baseline radiographic variables with good-to-excellent interobserver reliability. The posterior tilt angle, measured on a cross-table lateral x-ray, was used to classify the cohort into <20° (n = 183) and ≥20° (n = 49). The cumulative incidence with competing risk analysis was used to predict association between posterior tilt and subsequent conversion to arthroplasty. Patient survival was calculated with the Kaplan-Meier estimate.

RESULTS

Implant survival was 86.3% (95% confidence interval (CI) 80 to 90) at 12 months and 77.3% (95% CI 64 to 86) at 70 months. The 12-month cumulative incidence failure was 12.6% (95% CI 8 to 17). After controlling for confounders, posterior tilt ≥20° had higher risk of subsequent arthroplasty when compared to posterior tilt <20° (38.8 [95% CI 25 to 52] versus 5% [95% CI 2.8 to 9], subhazard ratio 8.3, 95% CI 3.8 to 18), without any other radiologic or demographic factor being associated with failure. Patient survival was 88.2% (95% CI 83 to 91.7) at 12 months, 79.5% (95% CI 73 to 84) at 24 months, and 57% (95% CI 48 to 65) at 70 months.

CONCLUSION

Cannulated screws were a reliable treatment for Garden I and II fractures, except when there was posterior tilt ≥20°, where arthroplasty should be considered.

Preoperative posterior tilt can be a risk factor of fixation failure in nondisplaced femoral neck fracture: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis aimed to identify whether posterior tilt increases the risk of treatment failure in nondisplaced femoral neck fractures.

METHODS

We searched the databases of the PubMed, Embase, and Cochrane Library from 1980 to 2022. The search strategy was based on the combination of keywords "nondisplaced," "hip fracture," "femoral neck fracture," and "internal fixation." Cohort studies enrolled patients with nondisplaced (Garden I and Garden II) femoral neck fractures were included. Two investigators independently extracted data and the other two assessed the methodological quality. Data were analyzed using Review Manager software.

RESULTS

We analyzed 13 cohort trials with a pooled sample of 4818 patients, with posterior tilt ≥ 20° in 698 patients and < 20° in 3578 patients in 11 trials, and posterior tilt ≥ 10° in 483 patients and < 10° in 496 patients in 4 trials. All studies were of high quality based on Newcastle-Ottawa Scale evaluation. Treatment failure was reported in 24.4% (170/698) of patients with posterior tilt ≥ 20° and 10.9% (392/3578) of patients with posterior tilt < 20°, indicating that posterior tilt ≥ 20° was significantly associated with a higher risk of treatment failure (Risk ratio, 2.73; 95% confidence interval [CI], 1.77-4.21). Posterior tilt ≥ 10° was not found to be a risk factor for fixation failure (risk ratio, 1.92; 95% CI 0.76-4.83).

CONCLUSION

Nondisplaced femoral neck fractures with posterior tilt ≥ 20° were associated with an increasing rate of failure when treated with internal fixation. LEVEL OF EVIDENCE : III, Systematic review and meta-analysis.

High Complication Rate After Percutaneous Screw Fixation for Valgus-Impacted Femoral Neck Fractures Without Sagittal Malalignment

OBJECTIVES

To evaluate the rate of reoperation in patients without sagittal plane malalignment who underwent percutaneous screw fixation of a valgus-impacted femoral neck fracture.

DESIGN

Retrospective case series.

SETTING

Two Level 1 academic trauma centers.

PATIENTS AND INTERVENTION

Two hundred seven patients >50 years of age with valgus-impacted femoral neck fractures treated with at least 3 large-diameter (>6.5 mm) cancellous screws from 2013 to 2019. Patients were excluded if there was a sagittal plane fracture deformity.

MAIN OUTCOME MEASUREMENTS

The primary outcome was reoperation. Secondary outcomes considered "major complications" included: avascular necrosis, varus collapse or implant cutout, nonunion, deep infection, and hematoma requiring reoperation. Surgical fixation strategies (screw configuration, aim) and implant type (partial vs. fully threaded cancellous screws) were secondarily compared.

RESULTS

Average patient age was 77 years, and median clinical follow-up was 658 days. Thirty-one patients (15%) required reoperation, and the major complication rate was 17.3% (36 complications in 33 patients). Logistic regression analysis demonstrated a higher risk of reoperation with constructs consisting of all partially threaded screws (17.0%) compared with the use of at least 1 fully threaded screw (7.5%) when an inverted triangle configuration was used (odds ratio, 2.50; 95% CI, 0.81-7.77).

CONCLUSIONS

This study demonstrated a relatively high rate of reoperation and major complications in patients with valgus-impacted femoral neck fractures without sagittal malalignment treated with in situ percutaneous screw fixation.

LEVEL OF EVIDENCE

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

Complications and Outcomes of the Internal Fixation of Non-displaced Femoral Neck Fracture in Old Patients: A Two-Year Follow-Up

Background Fractures of the proximal femur are amongst the most common injuries in the elderly population. While there is a clear consensus regarding the management of displaced femoral neck fractures, the management of non-displaced fractures is less clear. Both fixation and arthroplasty are valid treatment options. Internal fixation is a less invasive procedure, but it carries the risks of non-union and avascular necrosis (AVN) of the femoral head. The literature describes varying complication rates associated with these risks. We aim to describe a series of elderly patients above the age of 65 years with non-displaced fractures of the femoral neck who were treated with internal fixation. Our objectives are to determine the union rate and complications in this group and to elucidate the factors that influence these outcomes. Methods We conducted a retrospective review of all patients aged 65 years and older who presented with femoral neck fractures at our level 1 trauma unit between 2018 and 2020. Fractures were classified using the Garden classification system, and only those with Garden 1 or 2 fractures (non-displaced) were included. Preoperative radiographs or intraoperative fluoroscopy images were used to classify fractures using the Pauwels classification. Serial postoperative radiographs and clinical notes (up to 24 months postoperatively) were reviewed to assess the union rate and the development of complications. Both non-union and AVN were analysed for their associations with age, sex, Pauwels grade and comorbidities. A subgroup analysis of the complications was performed to elucidate their association with age groups (<80 and >80 years) and types of fixations (dynamic hip screws {DHS} and cannulated screws). Results A total of 148 patients, consisting of 60 males and 88 females, were included in the analysis. The patients had a mean age of 78.5 years (ranging from 65 to 98 years). The union rate without any degree of AVN was 90.7%, with six non-unions (4.05%) and six patients experiencing AVN (4.05%). No difference in outcome was detected between the two groups based on age. High (type 2 or 3) Pauwels grade (p = 0.05) and treatment with cannulated screws (p = 0.02) were indicated as significant factors for non-union. All patients who developed AVN were noted to have a comorbidity that is known to predispose them to AVN. Conclusion Our series shows a union rate of 90.7%, which is comparable to the union rates reported in other published literature. Our results suggest that age does not independently influence the outcome of fixation for these fractures. We conclude that fractures with vertical orientation (Pauwels grade 2 or 3), when treated with cannulated screws, are more likely to result in non-union. AVN is the second most common complication after non-union, which is also associated with other risk factors for AVN.

Sagittal deformity of Garden type I and II geriatric femoral neck fractures is frequently misclassified by lateral radiographs

The objective of this study was to determine the validity and inter-rater reliability of radiographic assessment of sagittal deformity of femoral neck fractures.

Design

This is a retrospective cohort study.

Setting

Level 1 trauma center.

Patients/Participants

Thirty-one patients 65 years or older who sustained low-energy, Garden type I/II femoral neck fractures imaged with biplanar radiographs and either computed tomography or magnetic resonance imaging were included.

Main Outcome Measurements

Preoperative sagittal tilt was measured on lateral radiographs and compared with the tilt identified on advanced imaging. Fractures were defined as "high-risk" if posterior tilt was ≥20 degrees or anterior tilt was >10 degrees.

Results

Of 31 Garden type I/II femoral neck fractures, advanced imaging identified 10 high-risk fractures including 8 (25.8%) with posterior tilt ≥20 degrees and 2 (6.5%) with anterior tilt >10 degrees. Overall, there was no significant difference between sagittal tilt measured using lateral radiographs and advanced imaging (P = 0.84), and the 3 raters had good agreement between their measurements of sagittal tilt on lateral radiographs (interclass correlation coefficient 0.79, 95% confidence interval [0.65, 0.88], P < 0.01). However, for high-risk fractures, radiographic measurements from lateral radiographs alone resulted in greater variability and underestimation of tilt by 5.2 degrees (95% confidence interval [-18.68, 8.28]) when compared with computed tomography/magnetic resonance imaging. Owing to this underestimation of sagittal tilt, the raters misclassified high-risk fractures as "low-risk" in most cases (averaging 6.3 of 10, 63%, range 6 - 7) when using lateral radiographs while low-risk fractures were rarely misclassified as high-risk (averaging 1.7 of 21, 7.9%, range 1 - 3, P = 0.01).

Conclusions

Lateral radiographs frequently lead surgeons to misclassify high-risk sagittal tilt of low-energy femoral neck fractures as low-risk. Further research is necessary to improve the assessment of sagittal plane deformity for these injuries.

Level of Evidence

Level IV diagnostic study.

Evaluation of the Posterior Tilt Angle in Predicting Failure of Nondisplaced Femoral Neck Fractures After Internal Fixation: A Systematic Review

OBJECTIVE

To evaluate the posterior tilt angle (PTA) in predicting treatment failure after internal fixation of nondisplaced femoral neck fractures as graded by the Garden classification, which is based solely on anterior-posterior radiographic evaluation.

DATA SOURCES

A search was conducted of all published literature in the following databases from inception to December 20, 2021: PubMed, Embase, Cochrane Library, Web of Science, Scopus, and ClinicalTrials.gov .

STUDY SELECTION

We included English-language randomized controlled trials, prospective and retrospective cohort studies that reported malunion/nonunion, avascular necrosis, fixation failure, or reoperations in patients with nondisplaced femoral neck fractures treated with internal fixation who were evaluated for PTA using either lateral radiograph or computed tomography.

DATA EXTRACTION

All abstract, screening, and quality appraisal was conducted independently by 2 authors. Data from included studies were extracted manually and summarized. The Methodological Index for Non-Randomized Studies criteria was used for quality appraisal.

DATA SYNTHESIS

Odds ratios with 95% confidence intervals were calculated for treatment failure, defined as nonunion/malunion, avascular necrosis, fixation failure, or reoperation, in cases involving preoperative PTA ≥20-degrees and <20-degrees. Statistical significance was set at P < 0.05.

RESULTS

Nondisplaced femoral neck fractures with PTA >20-degrees had a 24% rate of treatment failure compared with 12% for those <20-degrees [odds ratios, 3.21 (95% confidence intervals, 1.95-5.28); P < 0.001].

CONCLUSION

PTA is a predictor of treatment failure in nondisplaced femoral neck fractures treated with internal fixation. Nondisplaced femoral neck fractures with a PTA >20-degrees may warrant alternative treatment modalities.

LEVEL OF EVIDENCE

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

Addressing posterior tilt displacement during surgery to lower failure risk of sub-capital Garden types 1 and 2 femoral fractures

INTRODUCTION

Sub-capital femoral fractures (SCFF) are impacted or non-displaced in Garden types 1 and 2, respectively. Non-surgical treatment is protected weight-bearing combined with physiotherapy and radiographic follow-up in selected patients. Traditionally, in situ pinning is the surgical treatment of choice. The aim of this study was to estimate whether the valgus deformity in Garden types 1 and 2 (AO classification 31B1.1 and 31B1.2) SCFF is a virtual perception of a posterior tilt deformity and if addressing this deformity improves patients' outcomes.

MATERIALS AND METHODS

The records of 96 patients with Garden Types 1 and 2 SCFF treated in tertiary medical center between 1/2014 and 9/2017 were retrospectively reviewed. They all had preoperative hip joint anteroposterior and lateral radiographic views. 75 patients had additional computed tomography (CT) scans. Femoral head displacement was measured on an anteroposterior and axial radiograph projections and were performed before and after surgery. Preoperative 3D reconstructions were performed for a better fracture characterization, and assessment of the imaging was performed by the first author.

RESULTS

The average age of the study cohort was 73 years (range 28-96, 68% females). There were 58 right-sided and 38 left-sided fractures. Ninety patients had Type 1 and six patients had Type 2 fractures. The average preoperative posterior tilt was 15 degrees and the average valgus displacement was 10 degrees on plain radiographs compared to 28 degrees and 11 degrees, respectively, on CT scans. Posterior tilt was found with a virtual perception as valgus-impacted fractures. The postoperative posterior tilt was corrected to an average of 3 degrees and the valgus displacement to 5 degrees.

CONCLUSION

CT provides an accurate modality for measuring femoral head displacement and fracture extent. The posterior tilt displacement should be addressed during surgery to lower failure risk and the need for additional procedures.

IRB APPROVAL

TLV-0292-15.

LEVEL OF EVIDENCE

IV.

Finite element analysis of necessity of reduction and selection of internal fixation for valgus-impacted femoral neck fracture

This study compared the biomechanical characteristics of different treatment strategies based on finite element analysis. Posterior tilt and valgus angle were measured on X-ray from ten valgus-impacted femoral neck fractures, and 7 finite element models that were generated to compare the stress and displacement. The results showed that in the intact femur, von Mises stress was concentrated at the medial and inferior sides of the femoral neck. In valgus-impacted femoral neck fractures, von Mises stress was at the same locations but was 5.66 times higher than that in the intact femur. When 3 cannulated screws were used for internal fixation, anatomic reduction diminished the stress at the fracture end from 140.6 to 59.14 MPa, although displacement increased from 0.228 to 0.450 mm. When the fracture was fixed with a sliding hip screw (SHS) + cannulated screw, there was less stress at the fracture end and greater displacement with anatomic reduction than that without reduction (stress: 15.9 vs 37.9 MPa; displacement: 0.329 vs 0.168 mm). Therefore, the SHS + cannulated screw has superior biomechanical stability than 3 cannulated screws, and is recommended following anatomic reduction to treat valgus-compacted femoral neck fractures.

Preoperative Anterior and Posterior Tilt of Garden I-II Femoral Neck Fractures Predict Treatment Failure and Need for Reoperation in Patients Over 60 Years

The purpose of the present study was to estimate the effect of preoperative fracture tilt and to scrutinize the effect of anterior tilt on the risk of treatment failure in patients with Garden Type-I and II femoral neck fractures that are treated with internal fixation.

Blood biomarkers related to osteonecrosis of femoral head by internal fixation after Garden I femoral neck fracture: a cohort study

BACKGROUND

Internal fixation is currently considered the gold standard in treatment for femoral neck fractures in adults. However, osteonecrosis of the femoral head (ONFH) after internal fixation would occur in quite proportion of patients with femoral neck fracture, even in Garden I femoral neck fracture. The purpose of this study was to determine the association between the blood biomarkers (serum albumin, pre-albumin, total protein and total lymphocyte count) and ONFH following internal fixation of Garden I femoral neck fracture in adults.

METHOD

This is a single center cohort study, in which each patient who sustained a Garden I femoral neck fracture had been treated with internal fixation, and had adequate preoperative blood examinations. The serum albumin was categorized as ≥ 40g/L or < 40g/L. The pre-albumin was categorized as ≥ 22mg/dL or < 22mg/dL. The total protein was categorized as ≥ 65g/L or < 65 g/L. The total lymphocyte count was categorized as ≥1.1× 10⁹ /L or <1.1×10⁹ /L. Multivariate cox proportional hazards analysis was used to assess the association between blood markers and the osteonecrosis of femoral head during the 2-years follow-up period controlling the confounders.

RESULT

A total of 10 cases of ONFH were identified. Multivariate Cox regression analysis revealed that low total lymphocyte count and hypertension state were significant independent risk factors for ONFH after internal fixation for Garden I femoral head fractures.

CONCLUSION

Blood biomarkers were potential predictors for ONFH after internal fixation Garden I femoral neck fractures. We suggest that routine laboratory tests might can be used to assist surgeons to identify patients at great risk of ONFH.

Preoperative Posterior Tilt Increases the Risk of Later Conversion to Arthroplasty After Osteosynthesis for Femoral Neck Fracture

BACKGROUND

Femoral neck fractures (FNFs) are one of the most common injuries in the elderly. Treatment is either internal fixation or primary arthroplasty. The main aim of this study is to assess the risk factors associated with fixation failure leading to further arthroplasty in FNFs treated with cannulated screws.

METHODS

Data on internal fixations of FNFs performed at Turku University Hospital between January 1, 2012 and December 31, 2017 were collected retrospectively from the patient database. Radiographical measurements were performed for preoperative displacement and posterior tilt, postoperative displacement, reduction quality, and implant shaft angle.

RESULTS

Altogether 301 cases were included in the study. The overall reoperation rate was 25% and conversion to arthroplasty was performed in 16% of cases. In the multiple variant analysis, adjusted for age and gender, nondisplaced fractures with a 0°-20° preoperative posterior tilt had a significantly lower risk of later conversion to arthroplasty than did nondisplaced fractures with a ≤0° or ≥20° posterior tilt (odds ratio [OR] 4.0, 95% confidence interval [Cl] 1.8-8.6, P = .0005) and displaced fractures (OR 7.2, 95% CI 3.0-17.4, P < .0001). No statistically significant association was found between preoperatively nondisplaced fractures with a <0° or ≥20° posterior tilt and displaced fractures (OR 0.6, 95% Cl 0.2-1.3, P = .2).

CONCLUSION

Displaced fractures and fractures with a preoperative posterior tilt of <0° or ≥20° have a considerably increased risk of reoperation and conversion to arthroplasty. Primary arthroplasty should be considered as treatment for displaced FNFs and fractures with >20° or <0° posterior tilt, especially in fragile patients, to avoid further operations.

Minimally invasive removal of a deep-positioned cannulated screw from the femoral neck: A case report

BACKGROUND

Clinical femoral neck fracture is common. Based on patient age and fracture type, different surgical methods can be selected, including cannulated screw fixation of the femoral neck and artificial total hip joint or semi-hip joint replacement. When patients with femoral neck fracture are treated with cannulated screw fixation, a cannulated screw may be positioned too deep. The excessively deep-placed screw is difficult to remove and causes major trauma to the patient.

CASE SUMMARY

A patient with poliomyelitis and femoral neck fracture was treated with a cannulated screw that was placed too deep. A self-made auxiliary tool (made of a steel sternal wire) was used to remove the cannulated screw near the pelvic cavity.

CONCLUSION

The depth of the cannulated screw can be estimated before screw placement using an improved hollow screwdriver with a scale mark, thus improving the safety of screw placement and facilitating clinical use.

Treatment of Valgus-Impacted and Nondisplaced Femoral Neck Fragility Fractures in the Elderly

As the life expectancy of the worldwide population increases, the number of hip fractures in the elderly cohort is expected to grow. It is important for surgeons to critically analyze available treatment options for these injuries, with the goal of optimizing outcomes and minimizing complications. Femoral neck fractures make up approximately half of all hip fractures. Nonoperative treatment of valgus-impacted and nondisplaced (Garden I and II) femoral neck fractures has high rates of secondary displacement, osteonecrosis, and nonunion; only patients with notable risk for perioperative complications are treated nonoperatively. Surgical intervention is the standard of care, with options including internal fixation (IF) with multiple cancellous screws or a sliding hip screw, hemiarthroplasty, or total hip arthroplasty. Patients with a posterior tilt of greater than 20° have a high rate of revision surgery when treated with IF and may benefit from primary arthroplasty. Furthermore, primary arthroplasty has demonstrated lower revision surgery rates and equivalent postoperative mortality when compared with IF. Surgeons should be aware of the functional outcomes, complications, revision surgery rates, and mortality rates associated with each treatment modality to make a patient-specific decision regarding their care.

A three-dimensional measurement based on CT for the posterior tilt with ideal inter-and intra-observer reliability in non-displaced femoral neck fractures

Posterior tilt is associated with prognosis of non-displaced femoral neck fractures (FNFs). Knowledge of their association is critical and informs surgeons whether to choose internal fixation or arthroplasty in treatment of non-displaced FNFs. This study aimed to design a novel three-dimensional (3D) posterior tilt measurement and evaluate the intra- and inter-observer variability compared to two-dimensional (2D) measurement proposed by Palm. We hypothesized that 3D measurement would be more accurate and realistic with higher reliability. To test the hypothesis, three observers measured the posterior tilt on the radiographs of 50 non-displaced FNFs, twice with both methods. Intra- and inter-observer reliability for each measurement method used were determined. The measured angle was divided into two categories, at the cut-off of 20° for clinical practice simulation. Intra- and inter-observer reliability were identified for clinical effectiveness. The results indicated that inter- and intra-observer reliability for 3D measurement and its classification was almost perfect with an intraclass coefficient of 0.995 (0.994) and a kappa value of 0.927(0.947), respectively. Conversely, a substantial inter- and intra-observer reliability for the 2D measurement was obtained with an interclass coefficient of 0.764 as well as an intraclass coefficient of 0.773. The clinical validity for 2D measurement showed slight inter-reliability and moderate intra-reliability with a kappa value of 0.192 and 0.587, respectively. Hence, the novel 3D measurement appears to be more reliable with a strong inter- and intra-observer reliability measurement. Further clinical studies are needed to carry out to validate this hypothesis.

More than 20° posterior tilt of the femoral head in undisplaced femoral neck fractures results in a four times higher risk of treatment failure

PURPOSE

In this study, we aimed to determine the correlation between the preoperative posterior tilt of the femoral head and treatment failure in patients with a Garden type I and II femoral neck fracture (FNF) treated with the dynamic locking blade plate (DLBP).

METHODS

Preoperative posterior tilt was measured in a prospective documented cohort of 193 patients with a Garden type I and II FNF treated with the DLBP. The correlation between preoperative posterior tilt and failure, defined as revision surgery because of avascular necrosis, non-union, or cut-out, was analyzed.

RESULTS

Patients with failed fracture treatment (5.5%) had a higher degree of posterior tilt on the initial radiograph than the patients with uneventful healed fractures: 21.4° and 13.8°, respectively (p = 0.03). The failure rate was 3.2% for Garden type I and II FNF with a posterior tilt < 20° and 12.5% if the preoperative posterior tilt was ≥ 20°. A posterior tilt of ≥ 20° was associated with an odds ratio of 4.24 (95% CI 1.09-16.83; p = 0.04).

CONCLUSION

Garden type I and II FNFs with a significant preoperative posterior tilt (≥ 20°) seem to behave like unstable fractures and have a four times higher risk of failure. Preoperative posterior tilt ≥ 20° of the femoral head should be considered as a significant predictor for failure of treatment in Garden type I and II FNFs treated with the DLBP.

Role of preoperative posterior tilt on the outcomes of internal fixation of non-displaced femoral neck fractures: A systematic review and meta-analysis

INTRODUCTION

There has been an increased interest in the role of preoperative posterior tilt, as measured on lateral radiographs, on the outcomes of internal fixation of non-displaced femoral neck fractures (FNF). The goal was to assess the available evidence for this in the literature.

PATIENTS AND METHODS

PRISMA guidelines were followed. PubMed, Embase and Cochrane were searched on June 10th, 2020 for studies assessing the role of posterior tilt on outcomes of internal fixation of non-displaced FNF. Primary outcomes were non-union and fixation failure, avascular necrosis (AVN), treatment failure, and reoperation (excluding symptomatic hardware removal). Outcomes were reported in Odds Ratio (OR) with 95% confidence intervals [CI].

RESULTS

Fourteen studies and 3729 patients were included (mean age 76 years, 72% female, mean follow-up 25 months). Moderate evidence was noted for the following: patients with greater preoperative posterior tilt had an increased risk of non-union and fixation failure (OR 2.4 [1.3 - 4.3]; p = 0.006), no increased risk of AVN (p = 0.550), an increased risk of treatment failure (OR 6.0 [2.2 - 15.9]; p<0.001) and reoperation (OR 2.5 [1.4 - 4.4]; p = 0.002). Furthermore, a greater preoperative tilt of 9.0° [4.1° - 13.9°] for treatment failure and 6.1° [3.7° - 8.5°] (p<0.001) for reoperation were noted in the unsuccessfully treated groups when compared to the successfully treated groups. Four studies found a threshold for posterior tilt ranging from 7° to 20° CONCLUSION: There is moderate evidence that patients with non-displaced FNF and greater tilt have an increased risk of unsuccessful outcomes following internal fixation. Older patients with a preoperative tilt of ≥20° might benefit from arthroplasty surgery, although studies assessing the optimal threshold are needed.

Posterior tilt in nondisplaced femoral neck fractures increases the risk of reoperations after osteosynthesis. A systematic review and meta-analysis

OBJECTIVE

To conduct a systematic review on the effect of posterior tilt on reoperations, patient reported outcome measures (PROM) and functional outcome following osteosynthesis of undisplaced FNFs (uFNF).

MATERIAL AND METHODS

A search string was developed with the aid of a scientific librarian and the search was performed in PubMed, CINAHL and Embase. The studies were screened independently by two authors using Covidence. Data were extracted by two authors and quality assessment was performed using Robins-I tool. The meta-analyses were performed in STATA IC 16 using Risk Ratio as the primary effect estimate.

RESULTS

In total, 617 studies were screened and ten studies were included with a total of 3,131 patients. The mean age ranged from 68.3 to 85.0 years and the prevalence of posterior tilt ≥20° in the studies ranged from 4.5% to 27.6%. There were 10.3% reoperations when posterior tilt was <20° whereas there were 24.5% when posterior tilt was ≥20° The meta-analysis therefore demonstrated an overall risk ratio of 0.11 (95% confidence interval; 0.04-0.18). Only one study investigated functional outcome, using ADL as measurement, but found no significant difference. No studies investigated PROM. In general, the studies were assessed to be of poor quality mainly due possible bias and confounding.

CONCLUSION

A posterior tilt ≥20° leads to a higher risk of reoperations in uFNF. Even though the studies were of poor quality, the results suggest that we should include the measurement of posterior tilt in national guidelines.

Deep Learning Improves Osteonecrosis Prediction of Femoral Head After Internal Fixation Using Hybrid Patient and Radiograph Variables

Femoral neck fractures (FNFs) are a great public health problem that leads to a high incidence of death and dysfunction. Osteonecrosis of the femoral head (ONFH) after internal fixation of FNF is a frequently reported complication and a major cause for reoperation. Early intervention can prevent osteonecrosis aggravation at the preliminary stage. However, at present, failure to diagnose asymptomatic ONFH after FNF fixation hinders effective intervention at early stages. The primary objective of this study was to develop a predictive model for postoperative ONFH using deep learning (DL) methods developed using plain X-ray radiographs and hybrid patient variables. A two-center retrospective study of patients who underwent closed reduction and cannulated screw fixation was performed. We trained a convolutional neural network (CNN) model using postoperative pelvic radiographs and the output regressive radiograph variables. A less experienced orthopedic doctor, and an experienced orthopedic doctor also evaluated and diagnosed the patients using postoperative pelvic radiographs. Hybrid nomograms were developed based on patient and radiograph variables to determine predictive performance. A total of 238 patients, including 95 ONFH patients and 143 non-ONFH patients, were included. A CNN model was trained using postoperative radiographs and output radiograph variables. The accuracy of the validation set was 0.873 for the CNN model, and the algorithm achieved an area under the curve (AUC) value of 0.912 for the prediction. The diagnostic and predictive ability of the algorithm was superior to that of the two doctors, based on the postoperative X-rays. The addition of DL-based radiograph variables to the clinical nomogram improved predictive performance, resulting in an AUC of 0.948 (95% CI, 0.920-0.976) and better calibration. The decision curve analysis showed that adding the DL increased the clinical usefulness of the nomogram compared with a clinical approach alone. In conclusion, we constructed a DL facilitated nomogram that incorporated a hybrid of radiograph and patient variables, which can be used to improve the prediction of preoperative osteonecrosis of the femoral head after internal fixation.

Is percutaneous screw fixation really superior to non-operative management after valgus-impacted femoral neck fracture: a retrospective cohort study

PURPOSE

The optimal management of valgus-impacted femoral neck fractures remains controversial. Internal fixation is associated with significant rates of re-operation, while historical non-operative management strategies consisting of prolonged bed rest also resulted in patient morbidity. Our hypothesis was that screw fixation would have comparable failure rates to non-operative treatment and immediate mobilization for valgus-impacted femoral neck fractures.

METHODS

Retrospective cohort at a single academic Level I trauma center of patients with valgus-impacted femoral neck fractures (AO/OTA 31-B1) treated with percutaneous screw fixation (n = 97) or non-operatively (n = 28). Operative treatment consisted of percutaneous screw fixation. Non-operative treatment consisted of early mobilization. The primary outcome was a salvage operation. Patient demographics were assessed between groups.

RESULTS

More non-operatively treated patients were permitted unrestricted weight-bearing (WBAT; p = 0.002). There was no increase in complication rates or mortality, and return to previous ambulatory status was comparable between operatively and non-operatively treated patients. 35.7% (10/28) of non-operatively treated patients underwent a subsequent operation, compared to 15.5% (15/97) of patients with screw fixation (p = 0.03). Only WBAT was independently associated with treatment failure (OR 3.1, 95%CI 1.2-8.3, p =0.02). WBAT was predictive of treatment failure only in the non-operatively treated group (64.3%, 9/14 WBAT vs 8.3%, 1/12 partial, p =0.005).

CONCLUSION

After controlling for weight-bearing restrictions, we found no difference in failure rates between non-operative treatment and screw fixation. Non-operative treatment with partial weight-bearing had low failure rates, comparable complication and mortality rates, and equivalent functional outcomes to operative treatment and is reasonable if a patient would like to avoid surgery and accepts the risk of subsequent arthroplasty. Overall, there were relatively high failure rates in all groups.

The influence of the CT scan in the evaluation and treatment of nondisplaced femoral neck fractures in the elderly

BACKGROUND

The management of nondisplaced femoral neck fractures (FNFs) has evolved, with emphasis in radiographic features such as posterior displacement. However, the role of advanced imaging in this scenario is still not well defined. Therefore, our objective is to assess the impact of a computed tomography scan (CT) on interobserver agreement (IA) of fracture classification, posterior tilt measurement, and treatment decisions in nondisplaced FNF in elderly patients.

METHODS

Eleven patients with a nondisplaced (Garden 1-2) FNF were assessed by six hip surgeons. On a first stage, fracture classification, posterior tilt, and treatment plan (fixation/arthroplasty) were determined only with clinical information and X-rays. On a second stage, a CT was added. The kappa coefficient ( κ) and intraclass correlation coefficient (ICC) were used to determine IA.

RESULTS

IA for Garden classification was only slight in X-rays and with the addition of a CT, with a κ = 0.13 (0-0.28) and 0.18 (0.03-0.33), respectively. Conversely, posterior tilt measurement agreement was excellent in both schemes, with an ICC = 0.92 (0.83-0.98) and 0.92 (0.82-0.98). The IA for the proposed treatment was slight with X-rays ( κ = 0.44; 0.29-0.6), but moderate with the addition of a CT scan ( κ = 0.67; 0.52-0.82). Changes in surgical decision where made in 14 of 66 evaluations with an OR = 1.4 (0.62-3.2) for choosing an arthroplasty if a CT was used.

CONCLUSION

IA for fracture classification and posterior tilt evaluation in nondisplaced FNF was not altered by the usage of a CT. There is improvement in treatment agreement when a CT scan is added to conventional imaging, with changes in treatment in 21% of cases.

Predictors of early failure of the cannulated screw system in patients, 65 years and older, with non-displaced femoral neck fractures

BACKGROUND

Hip fractures represent the most common injury and the main cause of morbidity and mortality among patients 65 years and older. About 20% of all femoral neck fractures (FNFs) are non-displaced or valgus impacted, for which internal fixation with the cannulated screws system (CSS) is indicated.

AIMS

The aim of this study was to identify predictors of early failure of CSS.

METHODS

Patients with non-displaced FNFs (Garden type I and II) treated operatively using the CSS were enrolled. Their characteristics, Pauwels angle, and posterior tilt were assessed and related with outcomes. The primary outcome was fixation failure within 6 months.

RESULTS

259 patients were included with a mean age of 81.44 years. Most patients were female with ASA 3. The majority of fractures were classified as Garden I and Pauwels I. On average, Pauwels angle was 27°, while posterior tilt was 12°. A linear correlation between Pauwels angle and posterior tilt was found; the failure rate was 9.7%. Using the adjusted Cox competing risk regression analysis, posterior tilt was found to be independently associated with failure rate (sub-distribution hazard ratio or SHR 1.14 [95% CI 1.05-1.24], p = 0.0020). A posterior tilt greater than 18° resulted predictive of failure. The 1-year mortality rate was 12%.

CONCLUSIONS

Non-displaced Garden type II fractures, Pauwels type II or III fractures, and a posterior tilt greater than 18° represent radiographic predictors of CSS early failure in the elderly.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

Implant positioning (IMPO) in undisplaced femoral neck fractures: Association to reoperation and development of an IMPO scoring system

INTRODUCTION

This study aims to investigate whether implant positioning is associated to risk of reoperation following internal fixation of undisplaced femoral neck fractures (FNF) with a posterior tilt < 20° in patients > 65 years.

METHOD

Patients were retrieved from the Danish Multidisciplinary Hip Fracture Register in the period 2009-2013. The patients' health records and x-rays were reviewed for age, sex, implant, Charlson Comorbidity Index, mortality, reoperation, fracture classification and implant positioning. X-rays were measured for implant positioning using a pre-existing scoring system (the Schep score) as well as some additional measurements. Primary outcome was reoperation within 2 years. The study included 406 patients, 75% females and the median (range) age was 82 (65-99) years. Odds ratios (OR) are shown with 95% confidence interval.

RESULTS

There were 45 (11%) reoperations. Six measurements were individually associated to risk of reoperation: 1) Distance to inferior calcar < 1 or ≥ 6 mm, OR 2 (1.1-4), 2) Distance to superior cortex 10 mm, OR 2(1.1-5), 3) Tip-head distance < 3 or ≥ 20 mm, OR 2 (1.1-4), 4) Placement in the superior or inferior 15 mm, OR 2 (1.1-5), 5) Placement in the anterior 25 %, OR 6 (1.8-20), 6) Inter-implant angle ≥ 5°, OR 3 (1.4-8). The Schep score had no associated to reoperation, and therefore a new implant positioning (IMPO) score was developed. The IMPO score consists of 6 items; 1 point given for each acceptable implant placement. An IMPO score less than 5 had an increased risk of reoperation; 0-2 points OR 22 (7-71) and OR 5 (2-11) for 3-4 points, compared to a score of 5-6. Among the 207 patients with a score of 5-6, the reoperation frequency was 4%.

CONCLUSIONS

This study identified implant positioning as a predictor to an increased risk of reoperation in undisplaced FNF. The newly developed IMPO score seems promising for identifying risk of reoperation.

Validation of two methods to measure posterior tilt in femoral neck fractures

INTRODUCTION

Posterior tilt of the femoral head in femoral neck fractures (FNF) may influence stability of the fracture and may therefore affect the treatment outcome. Posterior tilt can be measured with different methods. The Lateral Garden Angle (LGA) has been used for this purpose for decades and more recently the Posterior Tilt Measurement (PTM) was introduced. Despite the fact that both methods (LGA and PTM) are used in multiple studies, they have never been compared for reliability in a direct study. The aim of this study is to analyze the intra and inter observer reliability of the LGA described by Garden and the PTM according to Palm.

METHODS

Four observers measured the posterior tilt on the radiographs of 50 FNF two times with both methods. Intra and inter observer reliability were determined for the LGA and the PTM.

RESULTS

The intra observer reliability for both methods is substantial with an intra class coefficient of 0.75. The inter observer reliability of the PTM is also substantial with an intra class coefficient of 0.75 compared to a moderate reliability of the LGA with an intraclass coefficient of 0.60.

CONCLUSION

Based on our results we believe the LGA and the PTM are both reliable methods to measure posterior tilt. Yet the Posterior Tilt Measurement seems to have a better inter observer reliability and therefore has a slight preference over the Lateral Garden Angle.

Study protocol: HipSTHeR - a register-based randomised controlled trial - hip screws or (total) hip replacement for undisplaced femoral neck fractures in older patients

BACKGROUND

Femoral neck fractures (FNFs), which are common in the older population, are associated with high mortality and morbidity. Some 20% of FNFs are undisplaced (uFNFs). The routine surgical procedure for uFNFs is internal fixation (IF) with 2-3 screws/pins with a reported reoperation rate in older patients (age ≥ 75 years) of up to 21%. The reoperation rate for hemiarthroplasties for displaced fractures is lower than for undisplaced fractures operated with IF. This study will aim to determine whether the outcome for older patients with an uFNF can be improved by replacing the hip instead of preserving it.

METHODS

A national multicentre, register-based, randomised controlled trial (rRCT) will be conducted. For this trial, 1440 patients, ≥75 years with an acute uFNF, will be allocated. Eligible patients will be identified by the Swedish Fracture Register (SFR) platform, which will notify the admitting orthopaedic surgeon of eligibility. After informed consent has been given and documented, patients will be randomised to either IF (control group) or arthroplasty (intervention group) within the SFR platform. Injury mechanism, fracture classification, date of injury, and type of treatment are registered in the SFR. Type and brand of arthroplasty, surgical approach, and fixation are obtained from the Swedish Hip Arthroplasty Register (SHAR). The study cohort from the SFR will be cross-checked with the National Patient Register and the SHAR for outcome variables at 2, 5, and 10 years. The primary outcome will be a composite variable comprising reoperation rate and mortality at 2 years postoperatively. Secondary endpoints will include reoperation rate and mortality as stand-alone variables. In addition, secondary endpoints will be patient-reported outcomes as measured by the Short Musculoskeletal Functional Assessment questionnaire at 1 year postoperatively as routinely collected within the SFR. Further secondary endpoints will include the occurrence of adverse events such as pneumonia, stroke or myocardial infarction and evaluation of the external validity of the study.

DISCUSSION

This large, multicentre, register-based randomised controlled trial could potentially shift the treatment of uFNFs in older patients towards primary hip arthroplasty in order to improve the outcome.

TRIAL REGISTRATION

The trial is registered at www.clinicaltrials.gov (NCT03966716); May 29, 2019.

Posterior and anterior tilt increases the risk of failure after internal fixation of Garden I and II femoral neck fracture

Background and purpose - Preoperative posterior tilt of the femoral head as seen on lateral radiographs has been reported to affect the risk of fixation failure in cases of minimally displaced femoral neck fractures (Garden I-II). We investigated radiological risk factors of treatment failure.Patients and methods - We included 417 patients (68% women, median age: 78 years (50-108) with a minimally displaced femoral neck fracture (Garden I-II) treated with internal fixation in a retrospective cohort study. The patients were followed for 3.4 years (2-14). Data on age, sex, housing, cognitive impairment, implant angulation, pre- and postoperative tilt, hip complications, and reoperations were recorded. The risk of fixation failure was assessed using Cox proportional hazards regression analysis.Results - The overall reoperation rate was 17%, and the rate of treatment failure (fixation failure, nonunion, avascular necrosis, or posttraumatic osteoarthritis) was 13%. Cox proportional hazard analysis revealed an increased risk of treatment failure with a preoperative posterior tilt of at least 20° and a preoperative anterior tilt greater than 10°. A failure occurred in 13 of the 65 patients with a posterior tilt of at least 20° and in 5 of the 9 patients with an anterior tilt greater than 10°.Interpretation - A preoperative posterior tilt of 20° and an anterior tilt greater than 10° in cases of Garden I and II femoral neck fractures increase the risk of fixation failure necessitating additional surgery. In this group of patients, there is a need for future interventional studies regarding the feasibility of primary hip arthroplasty.

Not All Garden-I and II Femoral Neck Fractures in the Elderly Should Be Fixed: Effect of Posterior Tilt on Rates of Subsequent Arthroplasty

BACKGROUND

Internal fixation is currently the standard of care for Garden-I and II femoral neck fractures in elderly patients. However, there may be a degree of posterior tilt (measured on preoperative lateral radiograph) above which failure is likely, and primary arthroplasty would be preferred. The purpose of this analysis was to determine the association between posterior tilt and the risk of subsequent arthroplasty following internal fixation of Garden-I and II femoral neck fractures in elderly patients.

METHODS

This study is a preplanned secondary analysis of data collected in the FAITH (Fixation using Alternative Implants for the Treatment of Hip fractures) trial, an international, multicenter, randomized controlled trial comparing the sliding hip screw with cannulated screws in the treatment of femoral neck fractures in patients ≥50 years old. For each patient who sustained a Garden-I or II femoral neck fracture and had an adequate preoperative lateral radiograph, the amount of posterior tilt was categorized as <20° or ≥20°. Multivariable Cox proportional hazards analysis was used to assess the association between posterior tilt and subsequent arthroplasty during the 2-year follow-up period, controlling for potential confounders.

RESULTS

Of the 555 patients in the study sample, 67 (12.1%) had posterior tilt ≥20° and 488 (87.9%) had posterior tilt <20°. Overall, 73 (13.2%) of 555 patients underwent subsequent arthroplasty in the 24-month follow-up period. In the multivariable analysis, patients with posterior tilt ≥20° had a significantly higher risk of subsequent arthroplasty compared with those with posterior tilt <20° (22.4% [15 of 67] compared with 11.9% [58 of 488]; hazard ratio, 2.22; 95% confidence interval, 1.24 to 4.00; p = 0.008). The other factor associated with subsequent arthroplasty was age ≥80 years (p = 0.03).

CONCLUSIONS

In this analysis of patients with Garden-I and II femoral neck fractures, posterior tilt ≥20° was associated with a significantly increased risk of subsequent arthroplasty. Primary arthroplasty may be considered for Garden-I and II femoral neck fractures with posterior tilt ≥20°, especially among older patients.

LEVEL OF EVIDENCE

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

Femoral neck shortening after internal fixation of Garden I fractures increases the risk of femoral head collapse

BACKGROUND

Arthroplasty has not been proven superior over internal fixation for the treatment of non-displaced femoral neck fractures. However, internal fixation has been followed by high rates of revision for mechanical complications and of femoral neck impaction within the first postoperative year. The objective of this study was to determine whether femoral neck impaction was associated with avascular necrosis (AVN).

HYPOTHESIS

Fracture healing with femoral neck shortening by impaction after internal fixation of a femoral neck fracture is associated with AVN.

MATERIAL AND METHODS

A single-centre retrospective study in patients with Garden I fractures managed by screw fixation was performed to compare outcomes in the groups with and without femoral neck impaction. Follow-up radiographs were assessed for evidence of the femoral neck impaction during fracture healing. The occurrence of AVN was the primary evaluation criterion. The secondary evaluation criteria were risk factors for impaction and complications.

RESULTS

Of the 75 included patients, 9 (12%) experienced AVN. Impaction was significantly associated with AVN (p=0.02; relative risk, 4.38). Significant risk factors for impaction were a higher body mass index (p=0.0003) and valgus-impacted fracture reduction between the radiographs at baseline and immediately after surgery (p=0.0001).

DISCUSSION

Femoral neck impaction was a significant risk factor for AVN after screw fixation of Garden I fractures. Valgus-impacted fracture reduction must receive careful attention during fixation. We suggest static internal fixation if the impaction is reduced on a traction table and advise caution when using parallel screws. The diagnostic and therapeutic strategy proposed here deserves to be evaluated in a prospective study.

LEVEL OF EVIDENCE

III, retrospective comparative study.

Three-dimensional analyses to predict surgical outcomes in non-displaced or valgus impaction fractures of the femoral neck: A multicenter retrospective study

INTRODUCTION

The aim of our study was to (1) report our surgical outcomes of internal fixation in patients with non-displaced or valgus impaction fractures of the femoral neck, (2) introduce our new three-dimensional assessment method using a combination of X-ray and CT imaging, and (3) determine which radiologic measurements significantly predicted fixation failure.

HYPOTHESIS

We hypothesized that high posterior tilt angle and retroversion angle are related to high incidence of non-union and osteonecrosis.

MATERIALS AND METHODS

From January 2009 to December 2016, 64 elderly patients in two institutions with non-displaced or valgus impaction fractures of the femoral neck who had internal fixation using multiple parallel cannulated screws were enrolled. To determine the independent predictors of non-union, osteonecrosis, and re-operation, various clinical variables and radiologic variables, including the valgus angle on coronal CT images, the posterior tilt angle on Lorenz images, and the retroversion angle on axial CT images, were analyzed.

RESULTS

Non-union was identified in nine of the 64 patients (14.1%) and nine of the 55 patients (16.4%) who achieved bony union had femoral head osteonecrosis with subsequent segmental collapse. The multiple logistic regression model showed that a low bone mineral density of the femur, a higher posterior tilt angle on Lorenz image, and a higher retroversion angle on axial CT images were independent predictors of non-union and re-operation.

DISCUSSION

Primary hip arthroplasty should be considered when a posterior tilt angle of more than 9 degrees on Lorenz images or a retroversion angle of more than 13 degrees on axial CT images is identified in patients with osteoporotic valgus impaction fractures.

TYPE OF STUDY AND LEVEL OF PROOF

III, Retrospective comparative study.

Is non-operative treatment still relevant for Garden Type I fractures in elderly patients? The femoral neck impaction angle as a new CT parameter for determining the indications of non-operative treatment

BACKGROUND

The indications of non-operative treatment of undisplaced femoral neck fractures are controversial. The objective of this study was to assess whether two computed tomography (CT) parameters, the femoral neck impaction angle (IA) and the femoral neck posterior tilt angle (PTA), were effective in predicting the risk of secondary displacement after non-operative treatment of Garden I femoral neck fractures in patients aged 65 years or over.

HYPOTHESIS

The working hypotheses were that the IA in the coronal plane and PTA in the axial plane predicted secondary displacement after non-operative treatment of Garden I femoral neck fractures, could be reproducibly and reliably measured on CT scans, and could serve to identify Garden I fractures at risk for secondary displacement after non-operative treatment.

METHODS

Forty-nine patients aged 65 years or over with Garden I fractures treated non-operatively were included in a prospective single-centre study. CT images were used to measure the IA as the position of the fracture line relative to the femoral head in the coronal plane and the PTA as the position of the femoral head centre relative to the femoral neck axis in the axial plane.

RESULTS

After non-operative treatment, secondary displacement occurred in 22 (45%) patients. The PTA was not significantly different between the groups with vs. without secondary displacement (p=0.62). IA values≤135° were significantly associated with secondary displacement (odds ratio, 11.73; 95% confidence interval [95%CI], 3.04-45.28; p=0.004). An IA≤135° was 72.73% sensitive and 81.48% specific for predicting secondary displacement. IA measurement was reproducible, with intra-class and inter-class Cohen's kappa values of 0.94 (95%CI, 0.90-0.97) and 0.9011 (95%CI, 0.83-0.94), respectively.

DISCUSSION

The IA measured on CT images may hold promise for identifying Garden I hip fractures at high risk for secondary displacement after non-operative treatment. IA measurement is reproducible and reliable and may help to determine the indications of non-operative treatment.

LEVEL OF EVIDENCE

II, prospective cohort study.

Cross-Table Lateral Radiographs Accurately Predict Displacement in Valgus-Impacted Femoral Neck Fractures

Background:

Femoral neck fractures are classified as nondisplaced (Garden types I and II) or displaced (Garden types III and IV) on the basis of anteroposterior radiographs. Cross-table lateral radiographs are important in the assessment of Garden type-I and II fractures as posterior tilt of the femoral head may influence treatment results. A posterior tilt of >20° has been associated with an increased risk of treatment failure after internal fixation, although the precision of these measurements has not been validated. Therefore, the purpose of the present study was to compare cross-table lateral radiographs with 3-dimensional computed tomographic (3D-CT) reconstructions of Garden type-I and II femoral neck fractures.

Methods:

Twenty-three patients presenting with Garden type-I and II femoral neck fractures that were verified on anteroposterior radiographs underwent CT scanning immediately after radiographic examination. 3D models of the fractured and uninjured femora were reconstructed from the CT images, and displacement of the 3D models was determined by superimposing the fractured and uninjured femora. We defined a coordinate system with its origin at the center of the uninjured femoral head with the x axis oriented medially; the y axis, posteriorly; and the z axis, cranially. Correlations between lateral radiographs and 3D models were assessed with the Spearman rank coefficient, mean difference, and limits of agreement.

Results:

Posterior tilt of the femoral head on lateral radiographs was strongly correlated with displacement of the femoral head along the y axis of the 3D models, with a correlation coefficient of 0.86 (p < 0.001). Correlations between the findings on lateral radiographs and displacements along the x or z axis were weak, with coefficients of −0.30 (p = 0.18) and 0.21 (p = 0.34), respectively. The mean difference between displacement on lateral radiographs and displacement along the y axis of the 3D models was smaller, and demonstrated a smaller limits-of-agreement interval, compared with the x or z axis.

Conclusions:

Our results demonstrated a strong correlation between posterior displacement of the femoral head on lateral radiographs and displacement along the y axis in 3D models of Garden type-I and II femoral neck fractures. This finding indicates that lateral radiographs provide an accurate assessment of posterior tilt.

Factors associated with the development of avascular necrosis of the femoral head after non-displaced femoral neck fracture treated with internal fixation

OBJECTIVE

To identify the factors with influence on the development of avascular necrosis of the femoral head (ANFH) in patients with non-displaced femoral neck fractures treated with internal fixation.

MATERIAL AND METHOD

Retrospective study of cases and controls. We included non-displaced femoral neck fractures treated with internal fixation, and that presented ANFH with a postoperative follow-up of at least 2 years. The baseline variables, active comorbidities of the patients, the time for surgery and the number of screws used for osteosynthesis were recorded. Comparisons were made between the groups, those that presented ANFH and those that did not. By area under the curve, the cut-offs of age and time for surgery were located.

RESULTS

An association between sex, active comorbidities and number of screws used and the development of ANFH was not observed. The cut-off points for age and time for surgery were≤69 years and≤43hours, respectively. No significant correlation was observed for the cut-off time for surgery. In the multivariate analysis, age≤69 years was a significant predictor of the development of ANFH (OR 4.6; 95% CI 1.1 to 17.9; P=.028).

CONCLUSIONS

The patients aged 69 years or younger were at increased risk of developing ANFH after undisplaced femoral neck fracture treated with percutaneous screws.

Bilateral symmetrical comparison of the proximal femur using 3D-CT models

PURPOSE

Superimposed three-dimensional (3D)-models obtained from CT-images have been used to evaluate displacement of femoral neck fractures, but this method assumes symmetrical anatomy of normal femurs. The present study aimed to compare the spatial orientation of the left and right proximal femur, thus establishing if 3D models can be used as a reference standard for the evaluation of fracture displacement.

METHODS

We generated 3D-CT-models of 20 patients with no skeletal pathology of the proximal femurs. Three observers independently determined the positions of the fovea and the femoral head, and a vector intersecting the centre points of the fovea and the femoral head defined the rotation. Differences in positions and rotations were determined by superimposing the 3D-CT-models of both femurs.

RESULTS

The mean distance (95% CI) between positions of the left and right fovea was 3.1 mm (2.7-3.4) and between the left and right femoral head 2.8 mm (2.6-3.0). The minimal detectable change was 2.8 for the fovea and 2.3 for the femoral head, and the repeatability coefficients between 2.1-2.7 and 1.0-2.9, respectively. Mean difference in rotation of the femoral head was 6° (5.3-6.6) with a minimal detectable change of 8.8 and repeatability coefficients ranging from 5.8 to 10.0.

CONCLUSIONS

Distances between the left and right femoral heads were larger than what could be explained by measurement error alone, suggesting that there may be minor side-to-side differences. However, these differences are small, and 3D-CT-models can be used as a reference standard to evaluate displacement of femoral neck fractures.

Outcomes of nondisplaced intracapsular femoral neck fractures with internal screw fixation in elderly patients: a systematic review

INTRODUCTION

Although the preferred treatment for displaced femoral neck fractures in the elderly is hip arthroplasty, the treatment for impacted or undisplaced femoral neck fractures (UFNF) is still a subject of controversy. Our purpose was to systematically review studies of elderly patients with UFNF treated with internal fixation using screws: (i) what is the reported mortality; (ii) what is the reoperation rate; (iii) what are the clinical and radiological outcomes; and (iv) what is the methodological quality of the included studies?

METHODS

This systematic review was performed through a search of PubMed and the Cochrane database using a structured search algorithm including studies enrolling patients older than 60 years old, with UFNF treated with internal fixation using screws. Our literature search returned 950 studies and 11 were selected for final abstraction.

RESULTS

6 studies reported mortality rate. At 1-year follow-up mortality was reported by 3 studies: 18.8%; 22%, and 19%. At 5 years, 1 study reported mortality rate of 42%. Overall reoperation rate was reported by 9 studies and ranged from 8%-19%, while conversion to hip arthroplasty was performed in the range between 8% and 16% according to 6 studies.

CONCLUSIONS

Internal fixation with cannulated screws for UFNF in the elderly is a valuable option, although it has substantial reoperation and mortality rates. Further prospective high-quality, randomised controlled trials are required to establish the optimal approach for the treatment of UFNF.

The influence of the hips position on measurements of posterior tilt in a valgus-impacted femoral neck fracture

INTRODUCTION

Lateral radiographs are important for the evaluation of Garden I and II femoral neck fractures. These fractures appear undisplaced in the anteroposterior view, but posterior tilt of the femoral head may still be present in the lateral view. The influence of posterior tilt is, however, debated, which could be caused by the use of non-standardized cross-table radiographs in the conflicting reports. The aim of this bone-model study was therefore to evaluate the influence of the hips position on measurements of posterior tilt.

MATERIALS AND METHODS

We generated models of a Garden I-II femoral neck fracture and the non-injured contralateral femur from CT reconstructions with a 3D-printer. Lateral radiographs of the models were obtained in positions ranging from 90° internal rotation (IR) to 90° external rotation (ER) and 0-80° flexion. Two investigators independently measured posterior tilt on 27 lateral radiographs obtained from each model.

RESULTS

The inter-tester ICC was 0.91 (0.84-0.94), standard error of measurement (SEM) 2.6, and minimal detectable change (MDC) 7.2. The median (range) posterior tilt for the fracture model was 21.9° (5.0, 33.8) and 23.6° (2.2, 28.6) for observer 1 and observer 2, respectively. The corresponding posterior tilt within the range of 10° IR to 40° ER and 0 to 30° flexion of the fracture model, was 27.3° (24.0, 33.8) and 26.3° (24.8, 28.6).

DISCUSSION

The range of posterior tilt measurements for positions of the proximal femur restricted from 10° IR to 40° ER and 0 to 30° flexion, was above the MDC for observer 1, and below the MDC for observer 2. These findings indicate that rotation and flexion affect measurements of posterior tilt, but the influence may be negligible for positions of the injured extremity that are clinically relevant during cross-table lateral radiographs. A larger study that accounts for variations in anatomy and fracture displacement is required to confirm these findings.

Eight orthopedic surgeons achieved moderate to excellent reliability measuring the preoperative posterior tilt angle in 50 Garden-I and Garden-II femoral neck fractures

Background

Studies of elderly patients with Garden-I and Garden-II femoral neck fractures (FNFs) suggest that a preoperative posterior tilt of the femoral head of at least 20° increases the risk of fixation failure. A recently published treatment algorithm recommended hemiarthroplasty over internal fixation for elderly patients with Garden-I and Garden-II FNFs and a preoperative posterior tilt of at least 20°. However, the reliability of the method used to measure the posterior tilt has not been assessed according to recommended standards for reliability trials.

Methods

Four orthopedic registrars and four consultants measured the posterior tilt angle in 50 preoperative lateral radiographs at two occasions six weeks apart. We estimated inter- and intrarater reliability by intraclass correlation coefficient (ICC). We also assessed repeatability by the repeatability coefficient (RC) and agreement by the minimal detectable change (MDC). Based on the suggested cutoff value of 20°, we reported the overall percentage and specific agreement for the choice of implant.

Results

Inter- and intrarater reliability for all raters was excellent with an ICC (95% CI) of 0.77 (0.69–0.85) and 0.77 (0.67–0.86), respectively. The RC was 13.9 and the MDC 14.1. Specific agreement for choosing arthroplasty was 61.3 and 54.6% for the first and second test occasion, respectively.

Conclusions

Eight orthopedic surgeons measured the posterior tilt in 50 Garden-I and Garden-II FNFs and achieved excellent inter- and intrarater reliability. However, variations in repeated measurements and variations in measurements made by different raters, as assessed by the RC and the MDC respectively, ranged from 13.9° to 14.1°. The variations in posterior tilt measurements should be taken into account when choosing the type of implant for elderly patients with Garden-I and Garden-II femoral neck fractures.

FEMORAL NECK FRACTURES GARDEN I AND II: EVALUATION OF THE DEVIATION IN LATERAL VIEW

Objective:

To evaluate the rate of deviation in the lateral radiographic incidence in patients with femoral neck fracture classified as non-diverted in the anteroposterior view (Garden I and II).

Methods:

Nineteen selected patients with femoral neck fractures classified as Garden I and II were retrospectively evaluated, estimating the degree of deviation in the lateral view.

Results:

Fifteen cases (79%) presented deviations in lateral view, with a mean of 18.6 degrees (±15.5).

Conclusion:

Most fractures of the femoral neck classified as Garden I and II present some degree of posterior deviation in the X-ray lateral view. Level of Evidence III, Retrospective Comparative Study.

A systematic review of undisplaced femoral neck fracture treatments for patients over 65 years of age, with a focus on union rates and avascular necrosis

BACKGROUND

It remains unclear whether conservative treatment should be used to treat the common undisplaced femoral neck fractures that develop in the elderly. Herein, we systematically review the rates of union and avascular necrosis after conservative and surgical treatment of undisplaced femoral neck fractures.

METHODS

We searched the EMBASE, PubMed, OVID, Cochrane Library, Web of Science, and Scopus databases for randomized controlled trials or observational studies that assessed the outcomes of conservative or surgical treatments of undisplaced femoral neck fractures. No language or publication year limitation was imposed. Statistical analyses were performed with the aid of the chi-squared test. We evaluated the quality of each publication and the risk of bias.

RESULTS

Twenty-nine studies involving 5071 patients were ultimately included; 1120 patients were treated conservatively and 3951 surgically. The union rates were 68.8% (642/933) and 92.6% (635/686) in the former and latter groups, respectively (p < 0.001). The avascular necrosis rate in the conservatively treated group was 10.3% (39/380), while it was 7.7% (159/2074) in the surgically treated group (p = 0.09).

CONCLUSIONS

Surgery to treat undisplaced femoral neck fractures was associated with a higher union rate and a tendency toward less avascular necrosis than conservative treatment.

Reoperations and mortality in 383 patients operated with parallel screws for Garden I-II femoral neck fractures with up to ten years follow-up

INTRODUCTION

The objective of this study was to identify indications and predictors for subsequent surgeries in the same hip and to evaluate life expectancy following screw fixation of undisplaced femoral neck fractures (FNF). The study further aimed to determine the necessary follow-up time for future studies aiming to evaluate the treatment of such fractures.

MATERIALS AND METHODS

This is a single-center retrospective cohort study with prospectively collected data including skeletally mature patients with undisplaced FNFs operated between 2005 and 2013. Gender, age at fracture, American Society of Anesthesiologists score, smoking status and excess use of alcohol were retrieved from electronical medical records. Further, complications leading to all consecutive reoperations were registered along with time from primary operation to all reoperations, type of procedure during subsequent surgeries and time of death.

RESULTS

383 patients with a median (range) follow-up of 77 (23-125) months were identified. Within 1, 2 and 5 years from primary surgery, 8%, 17% and 21% respectively, had at least one subsequent surgery in the same hip. 10% of the patients underwent salvage arthroplasty, however, in long time survivors; conversion to arthroplasty was estimated in one out of four. Posterior tilt of the femoral head was a predictor for new surgeries due to instability of the bone-implant construct, but not for later avascular necrosis. For patients 70 years or older, the one-year mortality in men was 32% with an expected survival of approx. 2.5 years, compared to 17% and 5.5 years in women.

CONCLUSIONS

Screw fixation of undisplaced femoral neck fractures appears to be a safe procedure in particular in the absence of a posterior tilt of the femoral head. Conversion to arthroplasty was estimated to occur in one out of four of long time survivors. Men have a particularly poor medical prognosis and should receive careful medical attention. In order to capture 80% of reoperations, clinical studies and register studies must have a follow-up time of at least two years.

The influence of cognitive status on outcome and walking ability after hemiarthroplasty for femoral neck fracture: a prospective cohort study

INTRODUCTION

Femoral neck fracture (FNF) is a devastating injury with serious medical and social consequences. One-third of these patients have some degree of impaired cognitive status. Despite this, a high proportion of hip fracture trials exclude patients with cognitive impairment (CI). We aimed to evaluate whether moderate to severe CI could predict walking ability, quality of life, functional outcome, reoperations and mortality in elderly patients with displaced FNF treated with hemiarthroplasty (HA).

METHODS

This cohort study included a consecutive series of 188 patients treated with HA for a displaced FNF. Patients were assessed for estimated preoperative and 1 year postoperatively with regard to walking ability, cognitive status, quality of life with EQ-5D and hip function with Harris hip score.

RESULTS

There were 188 patients who met the inclusion criteria. A total of 130 patients were in the control group, and 58 were in the CI group. At 1-year follow-up, 31 patients (24%) had died in the control group and 22 patients (38%) had died in the cognitive impaired group. This difference in reoperation and mortality rate was statistically significant (log-rank test, p = 0.016). The CI had a significantly higher incidence of being non-walker (28 vs. 4%, OR 9.2, p = 0.001). The EQ-5D was higher in the control group, while the Harris hip score was comparable in the two groups.

CONCLUSIONS

Moderate to severe CI was associated with a high incidence of non-walking ability, worse quality of life, high mortality and re-operation rate after femoral neck fractures treated with HA.

Preoperative posterior tilt of at least 20° increased the risk of fixation failure in Garden-I and -II femoral neck fractures

Background and purpose - It has been suggested that preoperative posterior tilt of the femoral head may increase the risk of fixation failure in Garden-I and -II femoral neck fractures. To investigate this association, we studied a cohort of 322 such patients. Patients and methods - Patients treated with internal fixation between 2005 and 2012 were retrospectively identified using hospital records and the digital image bank. 2 raters measured the preoperative posterior tilt angle and categorized it into 3 groups: < 10°, 10-20°, and ≥ 20°. The inter-rater reliability (IRR) was determined. Patients were observed until September 2013 (with a minimum follow-up of 18 months) or until failure of fixation necessitating salvage arthroplasty. The risk of fixation failure was assessed using competing-risk regression analysis, adjusting for time to surgery. Results - Patients with a posterior tilt of ≥ 20° had a higher risk of fixation failure: 19% (8/43) as compared to 11% (14/127) in the 10-20° category and 6% (9/152) in the < 10° category (p = 0.03). Posterior tilt of ≥ 20° increased the risk of fixation failure, with an adjusted hazard ratio of 3.4 (95% CI: 1.3-8.9; p = 0.01). The interclass correlation coefficient for angular measurements of posterior tilt was 0.90 (95% CI: 0.87-0.92), and the IRR for the categorization of posterior tilt into 3 groups was 0.76 (95% CI: 0.69-0.81). Interpretation - Preoperative posterior tilt of ≥ 20° in Garden-I and -II femoral neck fractures increased the risk of fixation failure necessitating salvage arthroplasty. The reliability of the methods that we used to measure posterior tilt ranged from good to excellent.

A Guide to Improving the Care of Patients with Fragility Fractures, Edition 2

Over the past 4 decades, much has been learned about the pathophysiology and treatment of osteoporosis, the prevention of fragility fractures, and the perioperative management of patients who have these debilitating injuries. However, the volume of published literature on this topic is staggering and far too voluminous for any clinician to review and synthesize by him or herself. This manuscript thoroughly summarizes the latest research on fragility fractures and provides the reader with valuable strategies to optimize the prevention and management of these devastating injuries. The information contained in this article will prove invaluable to any health care provider or health system administrator who is involved in the prevention and management of fragility hip fractures. As providers begin to gain a better understanding of the principles espoused in this article, it is our hope that they will be able to use this information to optimize the care they provide for elderly patients who are at risk of or who have osteoporotic fractures.