Femoral neck fractures. 165 cases treated by multiple percutaneous pinning

Experience of valgus osteotomy for neglected and failed osteosynthesis in fractures neck of femur

PURPOSE

There is vast literature supporting valgus osteotomy in fracture neck of femur. However, little or no distinction has ever been made to evaluate the success of the procedure in these two different scenarios-non-unions due to failed osteosynthesis and neglected fractures neck of femur. The aim of our study was to compare the results of valgus osteotomy in neglected neck femur fractures and non-union fractures of neck of femur.

METHODS

This is a single tertiary centre-based retrospective study. The records of all patients aged less than 45 years who underwent valgus osteotomy for neck of femur fractures from 2012 to 2017 were evaluated. Patients with fracture neck of femur of over one month's duration, where no previous surgical intervention was undertaken were placed in neglected fracture group. Patients with failed primary osteosynthesis surgery, either cannulated cancellous screw or dynamic hip screw, were placed in fixation failure group. There were 23 patients in neglected group and 17 patients in fixation failure group. Demographical details, fracture patterns, and preoperative radiograph, surgery time, blood loss, post-operative complications, union time, and non-unions were studied in both groups.

RESULTS

Osteotomy site united in mean time of 11 weeks in fixation failure group and 11.3 weeks in neglected group (p = .434). Time to radiological union of fracture was 16 weeks (12-23 weeks) for neglected fracture group compared to 25 weeks (20-32 weeks) for fixation failure group which was statistically significant (p = .02). Seven out of 17 fractures did not unite in fixation failure group compared to one non-union out of 23 patients in neglected group. (p = .004) There were two loss of fixation with implant failure in fixation failure group compared to none in neglected group (p = .174). Neither of the groups had any surgical site infection.

CONCLUSION

Valgus osteotomy results in excellent union rates for neglected fractures of neck of femur. However, the union rates of valgus osteotomy are lower in neck femur fractures with failed implants compared to neglected fractures and the procedure should be cautiously used in such circumstances.

A Prognostic Algorithm for Assessment of Subcapital Femoral Neck Fractures

A new method for prognostication of non-union in subcapital femoral neck fractures is presented. From routine pre- and postoperative films from 112 patients with Garden stage 2, 3, and 4 fractures 4 parameters were obtained: Cranial displacement, orientation of the nail in the femoral head, depth of nail inserted, and attainment of perfect reduction. These 4 variables were combined into a simple algorithm capable of non-union prediction at various levels of certainty (74–100%).

Percutaneous fixation of proximal humerus fractures

Closed reduction and percutaneous fixation is a viable treatment option for displaced two-part, three-part, and valgus-impacted four-part proximal humerus fractures. Despite biomechanical studies demonstrating inferior stability compared with plate and intramedullary nail constructs, percutaneous fixation offers a minimally invasive approach with potential clinical advantages. Decreased scarring, improved cosmesis, and lower rates of avascular necrosis have been reported. Potential complications include pin migration, infection, avascular necrosis, neurovascular injury, and malunion. Clinical outcomes have been comparable with conventional techniques, with studies reporting approximately 70% good to excellent results.

Safety of computer-assisted surgery for cannulated hip screws

Computer-assisted orthopaedic surgery has developed considerably during the past few years. Several manufacturers produce hardware and software for use in trauma surgery. Validation of these systems before clinical application is mandatory to be sure they work accurately and safely. The accuracy of surgical performance is highly correlated with the cut-out percentages of hip screws. In a standardized operative setting, three cannulated hip screws were inserted in each of 20 sawbones. The screws were positioned either by fluoroscopic navigation technique or by conventional operative technique depending on randomization. Our primary aim was to assess whether computer-navigated screw fixation is equally safe compared with conventional screw fixation using fluoroscopy. To determine safety, we investigated number of drilling attempts, screw position, and radiation time. Secondary to these safety parameters, we also compared the operating time between the two procedures to assess the efficiency of computer navigation. Statistical analysis showed no differences regarding accuracy of screw position. Computer-assisted surgery resulted in fewer drilling attempts and less radiation time, with a similar operation time. We believe the currently used navigation system is safe and accurate.

Osteosynthesis and primary valgus intertrochanteric osteotomy in displaced intracapsular fracture neck of femur with osteoporosis in adults

Fifty-three adults sustaining intracapsular femoral neck fractures (subcapital 38 and transcervical 15) with osteoporosis were treated primarily by osteosynthesis with valgus intertrochanteric osteotomy. Final evaluation was done in 50 patients (1 patient died and 2 lost to follow up, were not considered). Union was achieved in 47 (94%) patients in an average period of 12.2 weeks (range 10-18 weeks) with 100% union at osteotomy site. An axial collapse between 2 and 14 mm was observed in 74% of patients at the fracture site. Average neck shaft angle achieved was 141 degrees . Retroversion of the femoral head was seen in 28% of patients postoperatively, but none demonstrated a further posterior tilt of proximal femoral fragment, thus preventing implant cut through. One of the four patients with avascular necrosis of the femoral head exhibited late segmental collapse between 98 and 171 weeks. Final results were excellent to good in 76% of patients (average hip score 92), fair in 18% (average Harris hip score 73) and poor in 6% (average Harris hip score 30). Deep infection in 2%, superficial infection in 4%, implant penetration into the joint in 4%, limb length discrepancy in 6% and external rotation in 68% were other complications. Primary osteosynthesis with valgus intertrochanteric osteotomy is a dependable procedure to provide stable fixation in fresh fractures of the neck of femur with osteoporosis. The potential benefit of retaining a viable biologic joint justifies the usefulness of this procedure.

Hemodynamic measurement in the femoral head using laser Doppler

The author used a laser Doppler device to measure hemodynamics in the femoral head. Twenty-eight patients with femoral neck fractures, 16 patients with intertrochanteric fractures, and 14 patients with osteoarthritis were studied. Through a lateral approach, a small hole was drilled into the femoral head using a burr, and a probe was inserted to measure intramedullary flow. The flow measurements were high and sinusoidal in shape (corresponding with the heart rate) in all Garden 1, all Garden 2, and in four of six Garden 3 femoral neck fractures. Flow measurements were low and not sinusoidal in two of six Gardens 3 and all Garden 4 fractures. Hemodynamic values were high in all 16 patients with intertrochanteric fractures and all 14 patients with osteoarthritis. Although the posterior column arteries were cut while the intramedullary hemodynamics were being measured in patients with osteoarthritis of the hips, the measured values still were high. The postero-lateral area of the femoral head was fed compensatorily by the inferior retinacular arteries. The laser Doppler is useful in estimating circulatory compromise.

Utilization of a partially threaded Kirschner wire in the treatment of femoral neck fractures

OBJECTIVE

This report introduces a new type of pin for treatment of femoral neck fractures.

DESIGN

Retrospective analysis.

METHODS

The pin used in this study has a tapered thread in its middle portion to facilitate fixation in the lateral femoral cortex, as well as a simple tip that allows percutaneous pinning without displacement of the reduced position. Between 1978 and 1993, we used our pins on 218 hips in 214 patients, all age sixty years or more. We were able to observe postoperative osteosynthesis in 176 hips (172 patients) during a mean follow-up period of thirty-two months; the incidence of osteosynthesis and local postoperative complications was also charted.

RESULTS

Osteosynthesis was obtained in 153 hips (87 percent); for groups based on Garden's classification, results were as follows: twenty-four of twenty-four hips in type 1, fifteen of sixteen in type 2, sixty-three of seventy-one in type 3, and fifty-one of sixty-five in type 4. Some local postoperative complications were observed, including second fractures at the pin insertion point (three hips), pin penetration of the femoral head (twenty-four hips), and pin slippage (three hips).

CONCLUSION

This pin is effective in the treatment of femoral neck fractures and has the added benefits of being minimally invasive and low in cost.

Rigid osteosynthesis decreases the late complication rate after femoral neck fracture. The influence of three different osteosynthesis devices evaluated in 369 patients

The influence of three different fixation devices on late healing complications after femoral neck fractures was studied in a large patient group from three different hospitals. Except for the choice of device, which was unique to each hospital, all other factors having a potential influence on the late outcome, such as sex and age of the patients, initial degree of fracture dislocation and quality of surgical reduction were similar among the three groups. Within a 2-year observation period the incidence of late segmental collapses (14%-19%) was not related to choice of device, but a higher number of non-unions (27%-30%) occurred after adaptive non-rigid methods using screws (von Bahr) or a flanged nail (Rydell) than after a more rigid osteosynthesis (8%, Deyerle). Using such a rigid fixation, the complication rate could be reduced by one-third and the need for revision surgery halved. A device providing stable fixation should be preferred for treatment of femoral neck fractures in the elderly to prevent the healing complications related to insufficient stabilization.

An algorithm for assessment of fracture displacement and pin positions in femoral neck fractures

A method for determination of both the displacement of the femoral head and the position of the fixation device in fixed femoral neck fractures is described. In routine AP and lateral radiographs of the hip, measurements are made of femoral neck-shaft angle, the diameter of the femoral head and neck, the distances from the center of the femoral head to the femoral neck axis and the distances from the femoral neck axis to the fixating screws. From these values the position of the femoral head and the fixating screws are determined by geometric calculations. A computer program in Q-BASIC was devised to perform the calculations and to produce graphic displays of cross-sections of the femoral head and neck, with the displacement of the head and the screw positions indicated. The accuracy of the method was evaluated by a new method using axial radiographs of hip specimens, which were compared with the computer-plotted graphs of the femoral head and neck. The mean error of the method was found to be +/- 5% of the femoral head diameter, approximately 2.5 mm.

Outcomes after displaced fractures of the femoral neck. A meta-analysis of one hundred and six published reports

Methods of meta-analysis, a technique for the combination of data from multiple sources, were applied to analyze 106 reports of the treatment of displaced fractures of the femoral neck. Two years or less after primary internal fixation of a displaced fracture of the femoral neck, a non-union had developed in 33 per cent of the patients and avascular necrosis, in 16 per cent. The rate of performance of a second operation within two years ranged from 20 to 36 per cent after internal fixation and from 6 to 18 per cent after hemiarthroplasty (relative risk, 2.6; 95 per cent confidence interval, 1.4 to 4.6). Conversion to an arthroplasty was the most common reoperation after internal fixation and accounted for about two-thirds of these procedures. The remaining one-third of the reoperations were for removal of the implant or revision of the internal fixation. For the patients who had had a hemiarthroplasty, the most common reoperations were conversion to a total hip replacement, removal or revision of the prosthesis, and débridement of the wound. Although we observed an increase in the rate of mortality at thirty days after primary hemiarthroplasty compared with that after primary internal fixation, the difference was not significant (p = 0.22) and did not persist beyond three months. The absolute difference in perioperative mortality between the two groups was small. An anterior operative approach for arthroplasty consistently was associated with a lower rate of mortality at two months than was a posterior approach. Some reports showed promising results after total hip replacement for displaced fractures of the femoral neck; however, randomized clinical trials are still needed to establish the value of this treatment.

Fracture of the femoral neck: identification of the optimal screw position by migration ratio

A consecutive series of fractures of the femoral neck treated with sliding screw and plate osteosynthesis were evaluated radiographically for the optimal position of the screw by use of migration indices. A naturally occurring optimal position of the screw was discovered. It was characterized by four positional indices in the head-neck region which were significantly correlated with minimal migration (or best stability). This optimal screw position gave a better prognostication of reduced risk of early fracture failure compared with the usual sectional division of the femoral head as indicator of screw position.

Cortical screw support in femoral neck fractures. A radiographic analysis of 87 fractures with a new mensuration technique

In 87 femoral neck fractures, operated on with 2 von Bahr screws and followed for up to 2 years, the positions of the fixating screws were determined with a new mensuration technique which compensates for the variations in hip rotation in routine radiographs. The union rate of the fractures was related to the position of the screws. A posterior placement of the proximal screw and an inferior placement of the distal screw in both the femoral head and neck improved the outcome substantially.

Garden grading of intracapsular fractures: meaningful or misleading?

A prospective study of 186 displaced intracapsular fractures treated by reduction and internal fixation found that the division into Garden grade 3 or grade 4 fractures had no predictive value in determining the quality of the reduction achieved, or the incidence of non-union. The value of the Garden classification of intracapsular fractures is questioned.

Femoral neck fracture fixation with hook-pins. 2-year results and learning curve in 626 prospective cases

We performed a prospective 2-year follow-up study of 626 consecutive femoral neck fractures treated with closed reduction and hook-pin fixation in all cases. The woman:man ratio was 2.9:1, the displaced:undisplaced fracture ratio 2.6:1. Mean patient age was 78 (18-100) years. The first 476 fractures were operated on by one of six surgeons with special interest in the technique, while the remaining operations were performed by any of the 35 surgeons in the department, all specialists in orthopedic surgery. Mortality within two years was 31 percent. Healing complications (redisplacement, nonunion or segmental femoral head collapse) in the total material/survivors only were for undisplaced fractures 5/7 percent, for displaced fractures 30/41 percent and for the total material 23/32 percent. According to life-table analysis, the complication rate in the total material at two years was 24 percent. The rate of secondary arthroplasty for healing complications was 13/19 percent. For displaced fractures, as well as for the total material, the group of specially interested surgeons had better results than the department as a whole.

Internal fixation of femoral neck fractures. Dynamic Hip and Gouffon screws compared in 73 patients

A prospective, randomized study comparing the Dynamic Hip screws and the Gouffon screws in the treatment of femoral neck fractures was terminated before the planned number of patients had been admitted, owing to a preponderance of early failure of the Gouffon screws (P 0.014); thus only 73 patients entered the study. After three years' follow-up, 25/38 Gouffon screws and 12/35 Dynamic Hip screws had failed. Six patients treated with Gouffon screws and 14 treated with Dynamic Hip screws had died. The outcome still favoured the use of Dynamic Hip screws (P 0.02).

Stability of femoral neck fracture. Roentgen stereophotogrammetry of 29 hook-pinned fractures

The stability of hook-pin fixation during weight bearing was studied in 29 femoral neck fractures using roentgen stereophotogrammetric analysis. Twenty-three fractures became stable within 1 to 9 months, whereas redisplacement or continuing movement of the fracture occurred in 6 cases. Displaced fractures shortened about 7 mm more than undisplaced ones before healing. The rotations of the femoral heads were greatest in the forward/backward direction, followed by varus-valgus tilting in both fracture groups. Rotation about the longitudinal axis was recorded in the displaced fractures, mainly as a retroversion, whereas no rotation occurred about this axis in the undisplaced fractures. Healing after 6 months, intermediate fracture fragments, and a decreased Pauwels' angle seemed to imply increased fracture compression or rotatory instability. Fractures that subsequently developed healing complications displayed an increased distal displacement of the femoral head during the first postoperative month.

Function after hook-pin fixation of femoral neck fractures. Prospective 2-year follow-up of 191 cases

Totally, 191 consecutive patients with femoral neck fractures during 1984 and 1985 had internal fixation with hook-pins and were prospectively investigated. Within 2 years, 62 patients had died and 47 had developed healing complications, 30 of whom had been treated with total hip replacement. Thus, 82 healed without complication. Forty-one of 47 patients without other handicaps affecting their walking ability considered their gait as good as it was preoperatively; 45 used no walking aids or a cane. Nine of 35 patients with a nonfracture-related disease affecting their walking ability managed to walk with or without a cane; 13 considered their walking ability unaltered compared with their prefracture state. Three of 82 patients complained of pain on walking and 2 of pain at rest. All but 1 could flex their hip 90 degrees or more. We believe that the function after internal fixation of cervical hip fracture with uncomplicated healing is superior to that achieved by primary hip replacement; primary replacement is recommended only in rheumatoid patients with displaced fractures.

Fixation of femoral neck fracture. Prospective comparison of von Bahr screws, Gouffon screws, and Hessel pins

We report a prospective study of 214 patients with femoral neck fractures operated on with multiple pinning. The fractures were randomly allocated to fixation with either von Bahr screws or Hessel pins in 1983 and 1984 or von Bahr or Gouffon screws in 1984 and 1985. After 2 years, the failure rate was one third in the von Bahr and the Gouffon screw groups and one half in the Hessel pin group. We conclude that the nonthreaded Hessel pin is inferior to the von Bahr and Gouffon screws for fixation of femoral neck fractures.

Internal fixation of femoral neck fracture. No difference between the Rydell four-flanged nail and Gouffon's pins

Two methods of internal fixation of femoral neck fractures were compared in a prospective randomized study of 223 patients. Radiographic evidence of early redisplacement, nonunion, or late segmental collapse occurred in 45 of 122 patients operated on with the Rydell four-flanged hook nail and in 33 of 101 patients operated on with Gouffon pins. According to the actuarial method of follow-up, the failure rates after 2 years were respectively 41 and 35 percent in the nail and pin groups, which is a nonsignificant difference.

Sequential scintimetry after femoral neck fracture. Methodologic aspects and prediction of healing complications

Forty-five patients with recent cervical hip fractures were included in a prospective, clinical, radiographic and sequential scintimetric study. Striking changes in radionuclide uptake over the entire hip region on the fracture side were found during the first 5 postoperative months. Fractures that healed without complications showed the highest relative femoral head uptake at 1 week and a peak value at 6 weeks, followed by a gradual decline at the subsequent examinations. Fractures with complications (redisplacement, nonunion, or late segmental collapse) showed a lower initial uptake and a more gradual increase and only a slight tendency towards increased uptake after 3 months. The accuracy in predicting nonunion with scintimetric examination alone is high both at 1 and at 6 weeks, and the accuracy is almost equally high with combined scintimetric, radiographic, and clinical assessment 3-5 months postoperatively.

Improved operations for femoral neck fracture. A radiographic evaluation

A radiographic investigation was undertaken to determine whether an increased interest in femoral neck fractures improved the operative result. In 1977, all femoral neck fractures were operated on by any of 30 surgeons of the orthopedic department, but in 1981 all fractures were operated on by one of six specially devoted surgeons. Preoperative fracture classification was performed with three parameters and proved equal in the 1977 and 1981 groups of 105 and 114 fractures, respectively. The quality of fracture reduction, determined with four parameters, was improved somewhat. The position of the nail(s), also determined with four parameters, improved considerably. The technical result was better in Garden IV fractures than in Garden III fractures. An increased interest in femoral neck fracture treatment improved reduction and fixation.

Early fixation failure in displaced femoral neck fractures

A study of 76 displaced femoral neck fractures treated by reduction and Knowles pins or AO (ASIF) cancellous bone screws was carried out. Fixation failure within 3 months occurred in 17 cases (22%). Advanced age, inaccurate reduction, a poor mental state of the patient, the number of Knowles pins used, and the preinjury functional ability of the patient are significant risk factors for fixation failure. Neurological disease, the type of fracture according to Garden, delay before operation, and the method of fixation are not significantly related to fixation failure.

Radionuclide scintimetry for diagnosis of complications following femoral neck fracture

A scintimetric study using Tc-99m MDP was made of 54 patients with delayed union, nonunion, or late segmental collapse of the femoral head, 4-92 months after femoral neck fracture. In radiographically verified collapse, the radionuclide uptake ratio between the femoral head on the fractured and on the intact side (HHR) was significantly higher than in fractures resulting in delayed union or nonunion. On the basis of scintimetric and radiographic findings, the patients with healing disturbances could be divided into three groups, characterized by the following features: Satisfactory post-reduction position of the fracture without subsequent redisplacement and a high HHR, which as a rule turned out to be delayed union; The same radiographic pattern but with a lower HHR, which in most cases resulted in nonunion; Inadequate reduction or early redisplacement of the fracture with a high HHR, which resulted in nonunion. The fractional precision in discriminating between different types of disturbed fracture healing by means of skeletal scintimetry was 0.86 in this study. This non-invasive and technically simple method would therefore be a valuable complement to radiography in the assessment of healing, more than 4 months after fracture of the femoral neck.

Osteosynthesis of femoral neck fracture. The sliding-screw-plate with or without compression

In a prospective study of 220 displaced femoral neck fractures treated with a sliding-screw-plate, the cases were allocated to osteosynthesis with or without compression. In surviving patients followed for at least 1 year, union occurred in 57/85 with compression and 58/71 without compression. At 2 years, necrosis was radiographically evident in 9/37 and 7/36 united fractures. Thus, compression cannot be recommended when displaced femoral neck fractures are treated with a sliding-screw-plate.

Axial compression in femoral neck osteotomies. A biomechanic study in human cadaver hips

The risk of applying compression to a sliding-screw-plate osteosynthesis in the treatment of femoral neck fractures was evaluated in an experimental study of 40 femoral neck osteotomies. Ten pairs of bones from autopsied women between 70 years and 79 years of age were compared to 10 pairs of bones from autopsied women of more than 80 years of age. The compression was applied intermittently but measured continuously. The results showed a diphasic curve. When the maximum axial compression force was reached, any attempt to apply further compression resulted in a rapid fall in pressure at the site of the osteotomy. The median of the maximum axial compression force was 971 N, ranging from 275 N to 1756N. The maximum axial compression forces were significantly lower in bones from women of more than 80 years of age compared to bones from women in the seventh decade. The clinical implication of the study is that compression of femoral neck fractures by a sliding-screw-plate system may be hazardous in patients with brittle bone, e.g. women over 80 years of age.

Moore prosthesis in the treatment of fresh femoral neck fractures. A critical review with special attention to secondary acetabular degeneration

A consecutive series of 106 patients with displaced femoral neck fractures was treated initially with Moore prostheses. The patients' mean age was 82.5 years (range, 67-91). At follow-up after two years, 71 patients attended. Thirty-seven per cent of these were in need of a conversion of their one-piece device to a total hip replacement on account of hip pain. When only active patients living in their own homes were considered, 55 per cent were found to need total hip replacements. The main reason for the development of hip pain was acetabular derangement. It was concluded that active patients, disregarding their age, should not be treated with one piece prostheses of their fractures could be satisfactorily reduced and pinned. If this cannot be accomplished, a primary total hip replacement may be considered.

Femoral neck fractures in young adults

Seventeen young adults with subcapital femoral neck fractures that occurred after injury and with no signs of osteoporosis were treated conservatively (2 cases) or by closed reduction and internal fixation. Evaluation of the results was based on clinical, radiological and scintigraphical examinations. The incidence of non-union was 24 per cent (4/17) and the incidence of avascular necrosis of the femoral head was 41 per cent (7/17). The total failure rate was 41 per cent as all fractures with non-union also had avascular necrosis. It was found that reduction was the most important factor determining the outcome, as only 17 per cent (2/12) of fractures with a good reduction subsequently developed non-union compared with 100 per cent (5/5) with malreduction. High-velocity injury was no more crucial than low-velocity injury. The final outcome of femoral neck fractures in young persons did not differ from the known outcome in elderly persons.

Dislocated femoral neck fractures. A follow-up study of 98 cases treated by multiple AO (ASIF) cancellous bone screws

A series of 98 dislocated femoral neck fractures were treated by closed reduction and osteosynthesis with multiple AO (ASIF) cancellous bone screws. The patients were followed up for 2 years (or until death). The degree of dislocation did not have a statistically significant influence on the failure rate, which was, however, significantly correlated with poor reduction. Thirty-nine percent of the fractures were complicated by non-union or late segmental collapse. Forty-three of the patients participated in the 2 year follow-up examination. Of these patients, 38 had achieved excellent or good hip function. It was concluded that the reduction was the most important single factor in treatment of these factors.

The Monk hard-top endoprosthesis for intracapsular fractures of the femoral neck

The Monk hard-top hip prosthesis has an acetabular cup of polyethylene, covered by a metal cap. The femoral stem is of two types, for insertion with or without acrylic cement. One hundred and sixteen patients of an average age of 78.5 years, who has sustained intracapsular fractures of the femoral neck of Garden type 3 of 4, were treated by Monk hard-top arthroplasty. After a mean follow-up time of 23.9 months (range 9-47 months), 73 survivors were re-examined clinically and radiologically. Using Love's classification it was found that in 34 cases (48 per cent) the result was excellent and in 21 cases (30 per cent) it was good. In 12 cases (17 per cent) the result was fair and in 4 cases (5 per cent) it was poor. The poor result in this latter-mentioned group was mainly due to medical diseases that interfered with walking. There was clinical and radiological evidence of an increased tendency of loosening of the uncemented prosthesis. Our numbers were, however, too small to draw definite conclusions about this. Our experience with the Monk hard-top endoprosthesis is satisfactory, but a longer time of observation will be required to establish whether this prosthesis is better than the conventional type for intracapsular fractures of the femoral neck.