The Result of In Situ Pinning for Valgus Impacted Femoral Neck Fractures of Patients over 70 Years Old

Simple Minimally Invasive Method to Reduce Valgus-Impacted and Tilted Femoral Neck Fractures without Soft Tissue or Cartilage Injury: Radiological and Clinical Results

OBJECTIVE

This is a rare study comparing the radiological and functional outcomes of fixation after reduction with in situ fixation group using Femoral Neck System (FNS). The aim of this study was to introduce a simple, innovative, minimally invasive method to reduce valgus-impacted and tilted femoral neck fractures without soft tissue or cartilage injury.

METHODS

A retrospective comparative analysis of 46 patients between May 2020 and February 2022 was performed. In the control group, 23 patients underwent in situ fixation without reduction. In the study group, another 23 patients were managed by fixation after reduction using a percutaneous pull-out technique with a full threaded Steinmann pin. Caput-collum-diaphysis (CCD) angle, tilt, and femoral neck shortenings were compared between the two groups. In addition, Harris Hip Score (HHS) was evaluated and compared at 1 year after surgery. Basically, independent samples t-test was used to compare radiological and functional results.

RESULTS

Patients' initial valgus and tilt angles were not significantly different between the groups (n.s.). However, the CCD and tilt angles measured immediately and at one year postoperatively were significantly different between the groups (p < 0.05). Regarding femoral neck shortening, shortening in the three directions, the x, y, and z vectors, was significantly less in the reduction group immediately postoperatively and at 1 year post-surgery (p < 0.05). The mean HHS at 1 year postoperatively was 79.7 ± 8.4 in the in situ fixation group and 87.9 ± 6.6 in the reduction groups, and there was a significant difference (p < 0.05).

CONCLUSION

The pull-out method with a threaded Steinmann pin to reduce valgus-impacted and tilted femoral neck fracture is safe and effective for accomplishing anatomical restoration. This may achieve successful bone union and maintain the femoral neck length and original tilt without nearby soft tissue or cartilage injury.

Multiple screw fixation versus cementless bipolar hemiarthroplasty for femur neck fracture using a nationwide hip fracture registry

Cementless bipolar hemiarthroplasty (BHA) recently gained popularity as a treatment for femur neck fracture (FNF), but there have been few studies comparing this with multiple screw fixation (MSF) in the elderly population. The purpose of this study is to compare (1) surgery-related parameters, (2) reoperation rate as a local complication, (3) in-hospital systemic complication rate, and (4) mortality rate at 1 year after MSF and cementless BHA in patients with FNF using nationwide data. Six-hundred sixty-six hips (aged ≥ 50 years) extracted from nationwide Hip Fracture Registry were included in this study (133 MSF and 533 cementless BHA). One hundred fifty-six hips were divided into nondisplaced FNF (Group A) and 510 into displaced FNF (Group B). We evaluated (1) surgery-related parameters (anesthesia type, time to surgery, operation time, estimated blood loss and volume of postoperative transfusion), (2) the rate of and reasons for reoperation, (3) the rate and type of in-hospital systemic complications and (4) one-year mortality rate after surgery. In Group A, MSF showed shorter operation time (p = 0.004) and lower incidence of in-hospital systemic complications (p = 0.003). In Group B, cementless BHA demonstrated lower reoperation rate than MSF (p < 0.001). In both Group A and B, cementless BHA was associated with higher estimated blood loss than MSF (p < 0.001). Based on findings in our study, MSF might be a more favorable option for nondisplaced FNF, whereas cementless BHA might be a better one for displaced FNF in patients older than fifty. Nevertheless, our nationwide study also showed that numbers of cementless BHAs were being performed for nondisplaced FNF even in teaching hospitals.

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.

Complications after internal screw fixation of nondisplaced femoral neck fractures in elderly patients: A systematic review

OBJECTIVE

Internal fixation with cannulated screws for nondisplaced femoral neck fractures in the elderly has substantial reoperation and mortality rates. The selection of either internal fixation or arthroplasty for nondisplaced femoral neck fracture is debatable.

METHODS

We performed a systematic review of the literature regarding complications in the internal fixation of nondisplaced femoral neck fractures in elderly (>60 years old) patients. We searched in multiple databases (PubMed, Web of Science, Embase, and Cochrane Library) for articles in this area; there was no limitation over the publication year.

RESULTS

A total of 1971 patients were identified from 16 published studies. All these patients were over 60 years old. The minimum follow-up after the surgical procedure was 11 months (range: 11-183 months). A total of 329 fractures (16.7%) with radiographic and clinical failures after fixation were identified with regard to stable femoral neck fractures. The single most common complication after surgery was nonunion (129/329), with a pooled percentage of 39.2%. Osteonecrosis was found to be the second most common cause of revision surgery (31.9%). The overall reoperation rate attributable to surgical complications was 15.2% (300/1971 patients). Conversion to hip arthroplasty was performed in 244 patients (12.4%) after primary fixation.

CONCLUSION

Our study elucidated further the complication rate of nondisplaced femoral neck fractures treated with internal screw fixation. Since the failure rate of screw fixation for stable femoral neck fractures in elderly patients is not low, we believe that hemiarthroplasty is a reasonable treatment option in select patients.

LEVEL OF EVIDENCE

Level III, Therapeutic study.

Innovative technique of minimally invasive closed reduction for impacted femoral neck fractures (MICRIF)

The moment arm of gluteus medius proportionated to distance from femoral head tends to be decreased postoperatively in valgus-impacted femoral neck fractures treated by in situ internal fixation. The aim of this article is to introduce a new gentle technique to correct the deformity. The innovative technique of Minimally Invasive Closed Reduction for Impacted Femoral neck fractures (MICRIF) mainly focused to disimpact valgus neck fractures into anatomical position. Patients were positioned on the fracture table to fix the hip joint in abduction and internal rotation. A 2.4-mm diameter Kirschner wire was inserted a few centimetres outside the iliac crest piercing the acetabular beak to enter the femoral head, followed by repositioning of the lower extremity from abduction into neutral. This method provides satisfactory anatomical reduction. Thereafter, a surgical implant was applied to osteosynthesize the reduced fracture. This simple technique effectively provides anatomical reduction in valgus impacted femoral neck fracture.

Surgical Outcomes of Internal Fixation Using Multiple Screws in Femoral Neck Fractures with Valgus Impaction: When Should We Consider Hip Arthroplasty? A Retrospective, Multicenter Study

Purpose

We analyzed the surgical outcomes at two institutions after internal fixation using multiple screws in femoral neck fractures with valgus impaction to determine independent predictors and their cut-off values for nonunion and reoperation.

Materials and Methods

Between January 2006 and December 2016, 104 femoral neck fractures with valgus impaction that underwent internal fixation using multiple screws from two institutions were enrolled. The multiple logistic regression model and receiver operating characteristics analysis were used to determine the independent predictors and cut-off values for nonunion and reoperation.

Results

There were 20 reoperations (19.2%) due to 11 nonunions (10.6%) and nine cases of femoral head osteonecrosis (8.7%). Multiple logistic regression analysis revealed that independent predictors of nonunion and reoperation were age and posterior tilt angle (P<0.05). The cut-off value for age and the posterior tilt angle for reoperation were 72.5 years and 12.2°, respectively. The patients with a posterior tilt angle of greater than 13° had poorer radiological and clinical outcomes compared with those with a posterior tilt angle of less than 13°, even though they did achieve bone union.

Conclusion

Primary hip arthroplasty should be considered in patients older than 73 years of age with a posterior tilt angle greater than 13°.

Result of Internal Fixation for Stable Femoral Neck Fractures in Elderly Patients

Purpose

This study was conducted to evaluate the results of internal fixation for stable femoral neck fractures occurring in patients over 65 years old.

Materials and Methods

Between 2008 and 2014, we evaluated 25 patients over 65 years old with Garden type 1 and 2 femoral neck fractures that were treated with internal fixation after a minimum follow up of 1 year. There were 5 males and 20 females and the average age was 72.3 years (range, 65-84 years) at the time of surgery. Fracture site union, horizontal shortening and complications were evaluated as radiographic parameters and change of walking ability (as measured using Koval walking ability score) was investigated as a clinical parameter.

Results

Union of fracture site was achieved in 24 out of the 25 cases (96.0%). The average length of horizontal shortening was 6.5 mm (range, 0.2-19.7 mm). At final follow up, 3 cases experienced complications: nonunion (n=1), avascular necrosis (n=1), and subtrochanteric fracture after minor trauma (n=1). Walking ability decreased an average of 1 step at the final follow up.

Conclusion

Internal fixation for stable femoral neck fractures occurring in patients over 65 years showed satisfactory union rates. However, care should be taken with this technique given the possibility of decreased walking ability resulting from horizontal shortening.