Long-Term Efficacy of Screw Fixation vs Hemiarthroplasty for Undisplaced Femoral Neck Fracture in Patients over 65 Years of Age: A Systematic Review and Meta-Analysis

Comparison of femoral neck system fixation outcomes in nondisplaced femoral neck fractures: a multicenter retrospective study of patients aged below and above 75 years

PURPOSE

The use of fixation and arthroplasty in treating elderly patients with nondisplaced femoral neck fracture (FNF) remains controversial. The femoral neck system (FNS) is known to have relatively stronger axial and rotational stability compared with cancellous screw fixation. This study aimed to evaluate how effective internal fixation using a FNS is for non-displaced FNF in elderly patients.

METHODS

All patients with nondisplaced (Garden I and II) FNF between July 2019 and November 2023 were eligible for osteosynthesis surgery at three institutions. Ninety-five patients (50 under 75 years of age and 45 over 75 years of age) who were treated with FNS with a follow-up period of more than 1 year were included. Clinical data (age, sex, direction, body mass index, injury mechanism, bone mineral density (BMD), and time to operation) were extracted from patient records. Institutional imaging software was used for radiographic analysis to evaluate surgical site complications at 1 year. Multivariate logistic regression analysis was performed to identify independent risk factors for reoperation.

RESULTS

The mean age of the younger group was 61.0 years, whereas that of the elderly group was 81.2 years. No significant differences were observed between the two groups except for BMD and time to operation. Three reoperations were observed in the younger group (6%), and four cases were observed in the elderly group (8.9%) (p = 0.894), and no significant difference in other surgical complications was observed between the two groups. BMD was identified as an independent risk factor for reoperation.

CONCLUSION

FNS may be used as an alternative to elderly and younger patients with nondisplaced FNFs. However, the reoperation rate may increase in severe osteoporosis patients with very low hip BMD.

Quality of life and cost-utility analysis in patients with femoral neck fracture: a propensity score matching study comparing monopolar hemiarthroplasty and total hip arthroplasty

INTRODUCTION

Femoral neck fracture impacts patients' quality of life. Patients treated with a total hip arthroplasty (THA) versus a hemiarthroplasty (HA) may have higher quality of life scores after the intervention. This work aims to analyze and compare quality of life among patients with femoral neck fracture treated with THA versus monopolar HA and to perform a cost-utility analysis (CUA) on the procedures.

MATERIALS AND METHODS

A prospective, comparative study was conducted on 424 patients with femoral neck fractures, 268 treated with monopolar HA and 156 with THA. To ensure comparability between the groups, Propensity Score Matching (PSM) was performed based on variables such as age and the Charlson Comorbidity Index. The index accounted for comorbidities including cardiovascular disease, diabetes, chronic pulmonary disease, renal disease, and malignancy. After PSM, 156 matched pairs were analyzed. Follow-up data, including quality of life (QoL) assessed via the EQ-5D scale, were collected at 1 year.

RESULTS

Twelve months after the procedure, patients treated with THA had significantly higher EuroQol-5D (EQ-5D) index values than those treated with monopolar HA (0.83 vs. 0.68; p = 0.001), with a large effect size (Cohen's d = 0.92), however, both procedures presented similar results on the EQ-5D visual analog scale (VAS) (86.59 vs. 87.11; p = 0.255). THA led to a gain of 0.15 quality-adjusted life years (QALY) compared to monopolar HA (0.83 QALY vs. 0.68 QALY) and demonstrated greater cost-effectiveness, particularly in patients younger than 80 years and those with fewer comorbidities.

CONCLUSIONS

Patients with femoral neck fracture treated with THA may have higher quality of life levels than those treated with monopolar HA. Likewise, the greatest gain in QALY with THA versus monopolar HA was observed in patients younger than 80 years of age and those who had less comorbidity.

Retrospective paired cohort study comparing internal fixation for undisplaced versus hemiarthroplasty for displaced femoral neck fracture in the elderly

INTRODUCTION

The debate continues regarding the best treatment for elderly patients with non-displaced femoral neck fractures (FNFs): internal fixation (IF) vs hemiarthroplasty (HA). The Aim of the present study is to compare surgical insult, mortality, complications, and walking recovery after one year in patients older than 65 treated with cannulated screws or HA for FNFs.

PATIENTS AND METHODS

Match-paired comparison of retrospective cohorts: 220 non-displaced FNFs treated with cannulated screws vs 220 displaced FNFs treated with bipolar HA from 2013 to 2021. No differences were observed in age (82.1 ± 7.5 IF vs 83±6.8 HA) (p = 0.172), sex (74.6 % IF females vs 74.6 % HA females) (p = 0.912), year of intervention (p = 0.638) and ASA scale (III in 55.5 % IF vs 55.9 % HA) (IV in 21.8 % IF vs 18.2 % HA) (p = 0.726). Medical complications analyzed included respiratory and urinary infections, heart failure, myocardial infarction, stroke, pulmonary embolism, deep vein thrombosis, acute digestive bleeding.

RESULTS

Lower surgical aggression in IF: surgical time (p < 0.001), hemoglobin and hematocrit decrease (p < 0.001), need for transfusion (p < 0.001), hospital stay (p < 0.001).

MORTALITY

higher in-hospital for hemiarthroplasties: 12 deaths (5.5 %) vs 1 (0.5 %) (p = 0.004) (RR=12, 1.5-91.5). No differences after 1 month (13 (6 %) in HA vs 9 (4.1 %) in cannulated screws) and 1 year (33 (15 %) in HA vs 35 (16 %) in IF). Medical complications showed no significant differences (p = 0.055).

SURGICAL COMPLICATIONS

No differences in surgical infections (5 HA (2.3 %) vs 2 IF (0.9 %);p = 0,253) or neurovascular injuries (3 HA (1,4 %) vs 2 IF (0.9 %); p = 1). HA: 10 dislocations (4.5 %), 11 periprosthetic fractures (5 %). Cannulated screws: 10 fixation failures (4.6 %), 9 non-unions (4.1 %), 16 ischemic necrosis of femoral head (7.3 %). Reoperation rate: 15/220 IF (6.8 %) and 8/220 HA (3.6 %) (p = 0.134).

FUNCTIONAL RESULTS

No differences were detected (p = 0.285): 111 osteosynthesis patients (50.45 %) and 99 HA (45 %) returned to their pre-fracture walking ability (p = 0.322). There were also no differences between groups in those patients with worsening of walking status: 108 (49 %) osteosynthesis and 118 (53,6 %) prosthesis (p = 0.412).

CONCLUSIONS

Cannulated screws in patients over 65 with non-displaced femoral neck fractures results in less surgical insult, lower in-hospital mortality, comparable medical and surgical complications, a similar re-operation rate, and functional outcomes equivalent to hemiarthroplasty.

LEVEL OF EVIDENCE

Level III (retrospective comparison of matched cohorts).

Diagnostic Test Performances for Identifying Periprosthetic Joint Infection in Hip Hemiarthroplasty

INTRODUCTION

Periprosthetic joint infection (PJI) is a devastating complication of hip hemiarthroplasty (HHA) that is not well-represented in the literature. Therefore, this study aimed to evaluate diagnostic markers for identifying PJI in patients after HHA and compare them with the most recent 2018 International Consensus Meeting on Musculoskeletal Infection criteria.

METHODS

A total of 98 patients (64 PJIs, 65.3%) were analyzed. Patients were identified by relevant Current Procedural Terminology and International Classification of Diseases-9/10 codes from 2000 to 2021 across a single healthcare system. Preoperative or intraoperative synovial fluid nucleated cell (NC) count, synovial polymorphonuclear (PMN) percentage, serum erythrocyte sedimentation rate (ESR), serum C-reactive protein (CRP), and serum white blood cell count were compared with Student t -test between aseptic and septic cohorts. Diagnostic utility and laboratory cutoff values were determined using receiver-operating characteristic curves and Youden index, respectively.

RESULTS

Mean values were significantly higher in the septic cohort for synovial NC count (120,992.2 versus 1,498.0 cells/μL, P < 0.001), synovial PMN percentage (91.3% versus 56.2%, P < 0.001), serum ESR (75.6 versus 36.3 mm/hr, P < 0.001), serum CRP (20.2 versus 125.8 mg/L, P < 0.001), and serum white blood cell count (8.5 versus 11.5 cells/μL, P < 0.001). Synovial NC count, synovial PMN percentage, and serum CRP had excellent PJI discriminatory ability with an area under the curve of 0.99, 0.90, and 0.93, respectively. Optimal cutoffs were 2,700 cells/μL for synovial NC count (100% sensitivity and 94% specificity), 81.0% for synovial PMN percentage (96% sensitivity and 89% specificity), 52.0 mm/hr for serum ESR (75% sensitivity and 80% specificity), and 40.0 mg/L for serum CRP (85% sensitivity and 92% specificity).

CONCLUSION

Our findings support the continued use of routine serum and synovial fluid tests for diagnosing PJI in HHA patients. Optimal cutoff values for both synovial fluid biomarkers were very close in alignment with the 2018 International Consensus Meeting criteria.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Cannulated screws versus dynamic hip screw versus hemiarthroplasty versus total hip arthroplasty in patients with displaced and non-displaced femoral neck fractures: a systematic review and frequentist network meta-analysis of 5703 patients

BACKGROUND

Our aim was to determine the best operative procedure in human participants with a displaced or non-displaced femoral neck fracture comparing cannulated screw (CS) fixation, dynamic hip screw (DHS) fixation, hemiarthroplasty (HA), and total hip arthroplasty (THA) in terms of surgical and functional outcomes, reoperation and postoperative complications.

METHODS

We searched PubMed, The Cochrane Library, Clinical trials, CINAHL, and Embase for randomized controlled trials (RCTs) or quasi-RCTs up to 31 July 2022. A frequentist network meta-analysis was performed to assess the comparative effects of the four operative procedures, using fixed-effects and random-effects models. Mean differences (MDs) with 95% confidence intervals (CIs) were estimated for continuous variables and odds ratios (ORs) with 95% CIs were estimated for binary variables.

RESULTS

A total of 33 RCTs with 5703 patients were included in our network meta-analysis. CS fixation was best in terms of operation time (CS: MD = - 57.70, 95% CI - 72.78; - 42.62; DHS: MD = - 53.56, 95% CI - 76.17; - 30.95; HA: MD = - 20.90, 95% CI - 30.65; - 11.15; THA: MD = 1.00 reference) and intraoperative blood loss (CS: MD = - 3.67, 95% CI - 4.44; - 2.90; DHS: MD = - 3.20, 95% CI - 4.97; - 1.43; HA: MD = - 1.20, 95% CI - 1.73; - 0.67; THA: MD = 1.00 reference). In life quality and functional outcome, measured at different time points with EQ-5D and the Harris Hip Score (HHS), THA ranked first and HA second (e.g. EQ-5D 2 years postoperatively: CS: MD = - 0.20, 95% CI - 0.29; - 0.11; HA: MD = - 0.09, 95% CI - 0.17; - 0.02; THA: MD = 1.00 reference; HHS 2 years postoperatively: CS: MD = - 5.50, 95% CI - 9.98; - 1.03; DHS: MD = - 8.93, 95% CI - 15.08; - 2.78; HA: MD = - 3.65, 95% CI - 6.74; - 0.57; THA: MD = 1.00 reference). CS fixation had the highest reoperation risk, followed by DHS fixation, HA, and THA (CS: OR = 9.98, 95% CI 4.60; 21.63; DHS: OR = 5.07, 95% CI 2.15; 11.96; HA: OR = 1.60, 95% CI 0.89; 2.89; THA: OR = 1.00 reference).

CONCLUSION

In our cohort of patients with displaced and non-displaced femoral neck fractures, HHS, EQ-5D, and reoperation risk showed an advantage of THA and HA compared with CS and DHS fixation. Based on these findings, we recommend that hip arthroplasty should be preferred and internal fixation of femoral neck fractures should only be considered in individual cases.

LEVEL OF EVIDENCE I

a systematic review of randomized controlled trials.

TRIAL REGISTRATION

PROSPERO on 10 August 2022 (CRD42022350293).

Internal Fixation Versus Hemiarthroplasty for Nondisplaced Femoral Neck Fractures: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare internal fixation (IF) versus hemiarthroplasty (HA) for elderly individuals (ie, older than 65 years) with nondisplaced (ie, Garden type I or II) femoral neck fracture (FNF).

DATA SOURCE

We searched English literature of MEDLINE, PubMed, and Embase from inception to December 4, 2021.

STUDY SELECTION

Eligibility criteria were randomized controlled trials (RCTs) compared IF versus HA for elderly individuals with nondisplaced FNF. Primary outcomes were Harris hip score (HHS), quality of life per European Quality of Life 5 Dimension (EQ-5D), and mortality. Secondary outcomes were complications, reoperation, intraoperative bleeding, operation duration, and length of hospital stay.

DATA EXTRACTION

Two authors separately extracted data and assessed the risk of bias of the included studies using Cochrane risk-of-bias tool.

DATA SYNTHESIS

Three RCTs yielding 400 patients were enrolled, of which 203 (50.7%) underwent IF. Internal fixation was inferior to HA with respect to 6-month HHS [mean difference (MD) = -8.28 (-14.46, -2.10), P = 0.009] and 1-year EQ-5D [MD = -0.07 (-0.14, -0.00), P = 0.04]. The 2 techniques were comparable regarding length of hospital stay (day), HHS at 1 and 2 years, EQ-5D at 2 years, and mortality. IF was inferior to HA in implant-related complication [20.1% vs. 6.0%, relative risk (RR) = 3.18 (1.72, 5.88), P = 0.0002] and reoperation rate [20.1% vs. 6.0%, RR = 3.30 (1.79, 6.08), P = 0.0001]. Hemiarthroplasty had a greater blood loss (mL) [MD = -138.88 (-209.58, -68.18), P = 0.001] and operation duration (min) [MD = -23.27 (-44.95, -1.60), P = 0.04] compared with IF.

CONCLUSION

HA is the preferred technique for nondisplaced FNF if early recovery, higher mobility, and better quality of life are priorities. The choice of fixation should be weighed on an individual patient level.

LEVEL OF EVIDENCE

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

A comparison of internal fixation and hemiarthroplasty in the management of un- or minimally displaced hip fractures in patients over 60 years old

BACKGROUND

The incidence of hip fractures in the elderly is increasing. Minimally displaced and undisplaced hip fractures can be treated with either internal fixation or hemiarthroplasty.

OBJECTIVES

To identify the revision rate of internal fixation and hemiarthroplasty in patients 60 years or older with Garden I or II hip fractures and to identify risk factors associated with each method.

METHOD

A retrospective analysis was conducted from 2 Major Trauma Centres and 9 Trauma Units between 01/01/2015 and 31/12/2020. Patients managed conservatively, treated with a total hip replacement and missing data were excluded from the study.

RESULTS

1273 patients were included of which 26.2% (n = 334) had cannulated hip fixation (CHF), 19.4% (n = 247) had a dynamic hip screw (DHS) and 54.7% (n = 692) had a hemiarthroplasty. 66 patients in total (5.2%) required revision surgery. The revision rates for CHF, DHS and hemiarthroplasty were 14.4%, 4%, 1.2% (p<0.001) respectively. Failed fixation was the most common reason for revision with the incidence increasing by 7-fold in the CHF group [45.8% (n = 23) vs. 33.3% (n = 3) in DHS; p<0.01]. The risk factors identified for CHF revision were age >80 (p<0.05), female gender (p<0.05) and smoking (p<0.05). The average length of hospital stay was decreased when using CHF compared to DHS and hemiarthroplasty (12.6 days vs 14.9 days vs 18.1 days respectively, p<0.001) and the 1 year mortality rate for CHF, DHS and hemiarthroplasty was 2.5%, 2% and 9% respectively.

CONCLUSIONS

Fixation methods for Garden I and II hip fractures in elderly patients are associated with a higher revision rate than hemiarthroplasty. CHF has the highest revision rate at 14.4% followed by DHS and hemiarthroplasty. Female patients, patients over the age of 80 and patients with poor bone quality are considered high risk for fixation failure with CHF. Hemiarthroplasty is a suitable alternative with lowest revision rates. When considering an internal fixation method, DHS is more robust than a screw construct.

Comparison of the Effect of Rhombic and Inverted Triangle Configurations of Cannulated Screws on Internal Fixation of Nondisplaced Femoral Neck Fractures in Elderly Patients

Objective

To investigate whether four‐screw fixation in rhombic configuration could improve the clinical outcomes and decrease the complication rate compared with three‐screw fixation in inverted triangle configuration in elderly patients with nondisplaced femoral neck fractures.

Method

From January 2018 to January 2019, 91 elderly patients with nondisplaced femoral neck fractures who were treated with a cannulated screw system were reviewed retrospectively. The inverted triangle configuration was applied in 51 patients and rhombic configuration in 40 patients. The demographic and perioperative information of the patients were extracted from medical records and surgical records. Variables including incision size, surgical blood loss, surgical time, fluoroscopy time, hospital stays, fracture union time, postoperative visual analogue scale (VAS) scores, and complications were compared between the two groups. Also, Harris hip score at the final follow‐up was used to evaluate the functional outcomes.

Results

All patients were followed up from 24 to 36 months, with an average of 29.75 months. The average age of patients was 72.37 ± 7.16 years. No significant differences were found between the two groups with regard to patients' age, gender, affected side, Garden classification, Pauwels classification and comminution of posterior wall (P > 0.05). We found shorter incision size (P < 0.001), less blood loss (P = 0.020), less surgical time (P = 0.026), and shorter fluoroscopy time (P < 0.001) in inverted triangle configuration group. However, shorter hospital stays (P = 0.001) and fracture union time (P = 0.002) were found in the rhombic configuration group. The VAS scores were lower in the rhombic configuration group at the first (P < 0.001) and third months (P = 0.010), but no significant difference was found at the sixth month (P = 0.075). Meanwhile, the total complication rate was relatively lower in the rhombic configuration group compared to the inverted triangle configuration group (P = 0.041). Harris hip score presented no significant difference between the two groups at final follow‐up (P = 0.078). No wound infection or cortical perforation occurred in either group.

Conclusion

Four‐screw fixation in rhombic configuration was superior to three‐screw fixation in inverted triangle configuration in the treatment of nondisplaced femoral neck fractures in elderly patients in terms of less early postsurgical pain, shorter fracture union time, and lower complication rate.

Early Results in Non-Displaced Femoral Neck Fractures Using the Femoral Neck System

Introduction

Femoral neck fractures in the elderly are a major event and are rising in incidence over the last decade. Advancing age and numerous comorbidities largely account for high mortality rate and require geriatric expertise. Treatment options are total hip arthroplasty (THA), hemiarthroplasty (HA) or osteosynthesis. Literature suggests THA or HA for better outcomes, although no clear guidelines exist.

Material and methods

A retrospective chart review was performed of 63 patients (80 ± 11 years; 32 women, 31 men) with Garden one femoral neck fractures treated between June 2018 and June 2020 with either HA or internal fixation with the Femoral Neck System (FNS). Primary outcome measures were surgical and non-surgical complication rates and best achievable mobilization during the hospital stay.

Results

Thirty four patients were treated with HA, and 29 with the FNS. Mobilization was measured using the Charité Mobility Index (CHARMI). No difference between age, ASA, CCI or preoperative CHARMI was found. The CHARMI was significantly lower in the HA group. No difference in surgical complications was found. The HA cohort showed more non-surgical complications, a longer ICU stay and more blood transfusions. Hospitalization was significant longer in the HA than the FNS cohort (15.1 ± 5.1 vs 9.8 ± 3.8 days). Radiographic controls were performed after 6 and 12 weeks. The FNS group showed a mean shortening of 3.3 mm. 4 of 21 patient had shortening >5 mm. 20 of 21 patients showed radiographic signs of bone healing after 3 months.

Conclusion

Early results with the FNS show faster recovery than patient with hemiarthroplasty. Internal fixation with the FNS may be an option in non-displaced femoral neck fractures. Further studies should be performed to better evaluate the FNS compared to traditional internal fixation methods and arthroplasty.