Outcomes of Cephalomedullary Nailing in Basicervical Fracture

Comparison of the Surgical Outcome between the Multiple Screw Fixation and Fixed Angle Devices for the Basicervical Femoral Neck Fractures

Introduction: Basicervical femoral neck fracture (FNF) is an uncommon type of femoral neck fracture and is associated with an increased risk of fixation failure due to its inherent instability. The purpose of this study was to compare the surgical parameters and reoperation rate between the use of a multiple cannulated screw (MCS) and fixed angle device (FAD) in treating basicervical FNFs. Methods: We retrospectively reviewed the records of 885 patients who underwent internal fixation between May 2004 and August 2019 to determine basicervical FNF with at least 12 months of follow-up. Among the identified 77 patients with basicervical FNF, 17 patients who underwent multiple cannulated screw (MCS) fixation and 36 patients who underwent fixed angle device (FAD) fixation were included. We compared the rates of fracture-site collapse and reoperations according to the fixation device. Results: Among the 53 patients with basicervical FNF, 13 patients (24.5%) sustained surgical complications (8 collapses of fracture site and 5 reoperations). The reoperation rate in the MCS group was significantly higher than that in the FAD group (23.5% vs. 2.8%, p = 0.016), without any significant difference in the collapse of the fracture site (11.8% vs. 16.7%, p = 0.642). Conclusions: Although basicervical FNF was rare among hip fractures, fracture site collapse was prevalent and prone to fixation failure. Surgeons should keep this in mind, and consider FAD for basicervical FNF.

[Influence of anterior fracture line on anterior cortical reduction loss after cephalomedullary nail fixation in intertrochanteric fractures]

Objective

To investigate the position of the anterior fracture line in AO/Orthopaedic Trauma Association (AO/OTA) type A2 unstable intertrochanteric fractures and its impact on the incidence of anterior cortical reduction loss after cephalomedullary nail fixation.

Methods

A clinical data of 95 patients with intertrochanteric fractures who met the selection criteria between April 2020 and February 2023 was retrospectively analyzed. All patients were treated with cephalomedullary nail fixation, and the intra- and post-operative imaging data were complete. Among them, there were 37 males and 58 females. The age ranged from 61 to 97 years, with an average of 79.6 years. The time from injury to operation ranged from 7 hours to 11 days, with an average of 2.8 days. According to the 2018-AO/OTA classification standard, there were 39 cases of type 31-A2.2 and 56 cases of type 31-A2.3. Intraoperative fluoroscopy was used to record the number of patients with satisfactory fracture alignment. The preoperative CT data were imported into Mimics17.0 software to simulate the fracture reduction and measure the distance between the anterior fracture line and the intertrochanteric line bony ridge. The fractures were classified as transcapsular fractures, extra-capsular fractures, and intra-capsular fractures according to the distance. CT three-dimensional reconstruction was performed within 2 weeks after operation to observe the number of patients with anterior cortical reduction loss. The postoperative anterior cortical reduction loss incidence in patients with satisfactory fracture alignment, and the relationship between postoperative anterior cortical reduction loss and the position of the anterior fracture line were observed.

Results

There were 52 cases (54.7%) of transcapsular fractures, 24 cases (25.3%) of extra-capsular fractures, and 19 cases (20.0%) of intra-capsular fractures. Among them, 41 of the 52 transcapsular fractures had satisfactory fracture alignment, and 4 (9.8%) of them experienced anterior cortical reduction loss after operation; 19 of the 24 extra-capsular fractures had satisfactory fracture alignment, and no anterior cortical reduction loss occurred; 16 of the 19 intra-capsular fractures had satisfactory fracture alignment, and 7 (43.8%) of them experienced anterior cortical reduction loss after operation. There was a significant difference in the incidence of anterior cortical reduction loss between groups ( χ 2=8.538， P=0.003). All patients were followed up 3-26 months (mean, 9 months). Among them, 91 cases had fracture healing, and 4 cases had nonunion.

Conclusion

In AO/OTA type A2 unstable intertrochanteric fractures, where the anterior fracture line is located within the joint capsule, there is a high risk of anterior cortical reduction loss after operation.

Cephalomedullary Nailing versus Dynamic Hip Screw Fixation in Basicervical Femoral Neck Fracture: A Systematic Review and Meta-Analysis

PURPOSE

Although many studies have reported the use of dynamic hip screws (DHS) and cephalomedullary nailing (CMN) for basicervical femoral neck fracture (BFNF), no clear treatment protocols have been recommended. The present study aimed to compare the surgical outcomes associated with DHS and CMN to determine the appropriate fixation method for BFNF.

MATERIALS AND METHODS

We systematically searched MEDLINE, Embase, and the Cochrane Library for studies published up to January 9, 2021 that compared the treatment outcomes between CMN and DHS in BFNF. The primary outcomes of the present meta-analysis were fracture union time, postoperative cut-out rate, and reoperation rate.

RESULTS

We included seven studies involving 353 cases of BFNF in our review. Of these, 206 patients were treated using CMN, and DHS were utilized in 147 patients. In a pooled analysis, the DHS group required a longer time to achieve fracture union compared to the CMN group [mean difference (MD): -0.41; 95% confidence interval (CI): -0.70, -0.12; p=0.006; I²=0%]. However, the cut-out and reoperation rates exhibited no statistically significant differences between the DHS and CMN groups [cut-out odds ratio (OR): 0.54; 95% CI: 0.10, 2.82; p=0.47; I²=24%, reoperation rate OR: 0.65; 95% CI: 0.15, 2.86; p=0.57; I²=19%, respectively].

CONCLUSION

Stable fixation using DHS and CMN does not show a significant clinical or radiographical difference in BFNF, and the implant can be selected based on the surgeon's preference.

The management of segmental femur fractures: the radiographic 'cover-up' test to guide decision making

BACKGROUND

Segmental femur fractures often pose management challenges regarding the optimal fixation choice and sequence of surgical events.

METHODS

Retrospective review of clinical records and radiographic data of adult patients with segmental femur fractures treated by a conceptual radiographic cover-up test to determine the ideal fixation method between January 2019 and December 2020.

RESULTS

Forty patients with 84 individual fractures underwent fracture fixation. The most consistent fracture combinations were intertrochanter-diaphysis (AO31A-AO32) fractures (25%, n = 10) and femur neck-diaphysis (AO31B-AO32) fractures (20%, n = 8). Compared to evidence-based fracture management, the gold standard treatment was used for the fixation of 78 fractures (93%). One patient required revision for fixation failure of a diaphyseal fracture, and two fractures, both open diaphysis injuries, developed fracture-related infections.

CONCLUSION

Anatomical alignment and high union rates are possible for segmental femur fractures treated by evidence-based fracture fixation principles. A conceptual radiographic cover-up test assists in matching the best possible implant for each fracture.

Biomechanical comparison of the femoral neck system and the dynamic hip screw in basicervical femoral neck fractures

The purpose of this study was to compare the fixation stability of proximal fragments and the mechanical characteristics in proximal femur models of basicervical femoral neck fracture fixed by the femoral neck system (FNS) versus the dynamic hip screw. The mean axial stiffness was 234 ± 35 N/mm in the FNS group and 253 ± 42 N/mm in the DHS group, showing no significant difference (p = 0.654). Mean values for x-axis rotation, y-axis rotation, and z-axis rotation after cycle load were 2.2 ± 0.5°, 6.5 ± 1.5°, and 2.5 ± 0.6°, respectively, in the FNS group and 2.5 ± 0.7°, 5.8 ± 2.1°, and 2.2 ± 0.9°, respectively, in the DHS group, showing no significant differences (p = 0.324, p = 0.245, and p = 0.312, respectively). The mean values of cranial and axial migration of screws within the femoral head were 1.5 ± 0.3 and 2.1 ± 0.2 mm, respectively, in the FNS group and 1.2 ± 0.3 and 2.4 ± 0.3 mm, respectively, in the DHS group, showing no significant differences (p = 0.425 and p = 0.625, respectively). The average failure load at vertical load was 1342 ± 201 N in the FNS group and 1450 ± 196 N in the DHS group, showing no significant difference (p = 0.452). FNS fixation might provide biomechanical stability comparable to that of DHS for treating displaced basicervical femoral neck fractures in young adults.

Treatment and outcomes of basicervical femoral neck fractures: A systematic review

PURPOSE

This study aims to systematically review the literature comparing surgical treatments options and respective failure rates for basicervical hip fractures.

METHODS

A comprehensive search of databases, including MEDLINE, Embase, Web of Science, and Cochrane Central for studies published in English on or before June 21, 2019 was performed. Selected search terms included "basicervical," "basi cervical," "AO/OTA type 31-B," "femoral neck fracture" AND "bone nails," "bone screws," "fracture fixation," "internal fixation," "arthroplasty," "cephalomedullary," "sliding hip screw," "ORIF," and "treatment outcome." We included studies that assessed outcomes of basicervical fracture fixation using open reduction internal fixation or arthroplasty. Two authors extracted the following data from each paper: study design, country, cohort year, definition of basicervical, intervention type, sample size, patient demographics, follow-up length, percent of fractures that required revision, and the percent of implants that failed.

RESULTS

Sixteen articles encompassing 910 patients were included. The main outcome was the percent of implants that required revision. The total revision rates were 8% (8 studies, 157 patients, range 0%-55%) for cephalomedullary nails, 7% (10 studies, 584 patients, range 0%-18%) for sliding hip screws, 23% (3 studies, 40 patients, range 16%-50%) for cannulated screws, 0% (1 study, 6 patients) for total hip arthroplasty, and 8% (2 studies, 13 patients, range 0%-11%) for hemiarthroplasty.

CONCLUSION

Management of basicervical fractures with SHS and CMN produces similar failure and re-operation rates. Limited evidence is available on the use of cannulated screws and arthroplasty, but available studies suggest that cannulated screws have an unacceptable revision rate (23%) while arthroplasty may be acceptable. Future studies examining the comparative efficacy of various fixation methods would benefit from strict definition of fracture type as well as consistent reporting of functional outcomes, re-operation rates, and mortality.

[Effectiveness of proximal femoral nail anti-rotation for high plane intertrochanteric femur fractures]

Objective

To evaluate the effectiveness of proximal femoral nail anti-rotation (PFNA) in treatment of high plane intertrochanteric femur fractures.

Methods

A retrospective analysis was performed on 33 patients who underwent closed reduction and PFNA fixation for high plane intertrochanteric femur fracture between January 2016 and June 2019. There were 12 males and 21 females with an average age of 75.1 years (mean, 47-89 years). The fractures were caused by falling from height in 21 cases, by traffic accident in 7 cases, and by other injuries in 5 cases. Fractures were classified as type A in 14 cases and type B in 19 cases according to self-defined fracture classification criteria; and as type 31-A1.2 in 14 cases and as type 31-A2.2 in 19 cases according to AO/Orthopedic Trauma Association (AO/OTA) classification criteria. The time from injury to operation was 2-5 days (mean, 2.7 days). The operation time, intraoperative blood loss, hospital stay, fracture reduction quality, fracture healing time, internal fixation failure, and Parker-Palmer score were recorded.

Results

The operation time was 40-75 minutes (mean, 55 minutes). The intraoperative blood loss was 50-150 mL (mean, 64 mL). The hospital stay was 5-15 days (mean, 8.7 days). All incisions healed by first intention. Twenty-eight patients were followed up 12-18 months with an average of 13.6 months. The fracture reduction quality was rated as excellent in 9 cases (32.1%), good in 17 cases (60.7%), and poor in 2 cases (7.1%) by Chang's criteria. Parker-Palmer score was 6-9 (mean, 7.9) at last follow-up.

Conclusion

High plane intertrochanteric femur fracture is a special type of intertrochanteric fracture, which can be diagnosed by imaging examination. PFNA fixation can achieve satisfactory results and prevent the occurrence of internal fixation failure effectively.

Intramedullary Nail Breakage and Mechanical Displacement in Patients with Proximal Femoral Fractures: A Commercial and Medicare Supplemental Claims Database Analysis

Objective

This study evaluated the rates and patterns of intramedullary nail (IMN) breakage and mechanical displacement for proximal femur fractures and the factors associated with their occurrence.

Patients and Methods

Patients with subtrochanteric, intertrochanteric, or basicervical femoral neck fractures treated with IMN from 2016 to 2019 were identified from commercial and Medicare supplemental claims databases and were followed for up to two years. Kaplan–Meier analysis estimated the cumulative incidence of and patterns of breakage/mechanical displacement. Multivariable Cox regression models evaluated the factors associated with breakage/mechanical displacement.

Results

A total of 11,128 patients had IMN fixation for subtrochanteric, intertrochanteric, or basicervical femoral neck fractures: (mean SD) age 75.6 (16.4) years, 66.2% female, 74.3% Medicare supplemental vs 26.7% commercial insurance. Comorbidities included hypertension (62.9%), osteoporosis (27.3%), cardiac arrhythmia (23.1%), diabetes (30.7%), and chronic pulmonary disease (16.3%). Most fractures were closed (97.2%), intertrochanteric or basicervical femoral neck (80.1%), and not pathological (91.0%). The cumulative incidence of nail breakage over two years was 0.66% overall, 1.44% for combination fractures, 1.16% for subtrochanteric fractures, and 0.49% for intertrochanteric or basicervical fractures. The cumulative incidence of mechanical displacement was 0.37% overall, 0.43% for subtrochanteric fractures, 0.42% for combination fractures, and 0.36% for intertrochanteric or basicervical femoral neck fractures. Half of the breakages occurred within five months after surgery and half of the mechanical displacements occurred within 75 days. Age 50–64 (vs 75+) and subtrochanteric or pathological fracture were more commonly associated with nail breakage. Complicated hypertension was more commonly associated with mechanical displacement.

Conclusion

The incidence of IMN breakage and mechanical displacement in US commercial and Medicare supplemental patients with proximal femur fractures from 2016 to 2019 was low (0.66% and 0.37%, respectively up to two years). Age 50–64 (vs 75+) and subtrochanteric or pathological fracture were more commonly associated with breakage. Complicated hypertension was associated with mechanical displacement.

Review on Basicervical Femoral Neck Fracture: Definition, Treatments, and Failures

Basicervical femoral neck fracture is an uncommon fracture that accounts for only 1.8% of all proximal femoral fractures. Previous studies have recommended that the choice of implant to treat this fracture should be similar to that of intertrochanteric fracture. However, in previous studies on basicervical fractures, the definition and treatment results of these fractures were different, and there were also debates on the implant that had to be used. Therefore, the purpose of this study was to review the studies that performed surgical treatment of basicervical femoral fractures and to assess the definition of basicervical fracture, the use of implants, and failure rates and clinical results. Study selection was based on the following inclusion criteria: (1) treatment outcome for basicervical femoral neck fracture was reported; and (2) dynamic hip screw, proximal femoral nail, or multiple screw fixation was used as treatment. PubMed Central, OVID MEDLINE, Cochrane Collaboration Library, Web of Science, EMBASE, and AHRQ databases were searched to identify relevant studies published up to March, 2020 with English language restriction. A total of 15 studies were included in this study. Differences were found in the definition of basicervical fracture, treatment results, rehabilitation protocol, and fixation failure rate. Definitions and treatment methods for basicervical fractures varied, and treatment outcomes also differed among the enrolled studies. Further research is needed that would be restricted to those fractures that conform to the definition of basicervical fracture.

Management of Low-Energy Basicervical Proximal Femoral Fractures by Proximal Femoral Nail Anti-Rotation

Objective

To evaluate clinical and radiological outcomes of proximal femoral nail anti‐rotation (PFNA‐II) devices and demonstrate the effectiveness of PFNA‐II for the treatment of basicervical fractures in elderly patients.

Methods

A retrospective review of all patients treated with PFNA‐II for a proximal femoral fracture between January 2013 and February 2017 at three different institutions (Shanghai General Hospital, Shanghai Punan Hospital and Shanghai Seventh People's Hospital) was conducted. The X‐ray films were strictly reviewed by three trauma surgeons and a professional radiology doctor. Patients over 60 years of age who met the following criteria were included: (i) sustained low‐energy trauma; (ii) a two‐part fracture; (iii) fracture line located at the base of the femoral neck and that was medial to the intertrochanteric line and exited above the lesser trochanter but was more lateral than a classic transcervical fracture. Follow‐up time should be longer than 6 months. A total of 52 patients who met the inclusion criteria were selected. The average age at diagnosis was 75.1 years (range, 63–91 years); 13 patients were men and 39 were women. The same proximal femoral nail anti‐rotation devices and the same surgical procedures were applied to all patients. Postoperative radiographic union time and modified Harris hip scores were used as major indicators for evaluating the effectiveness of surgery.

Results

The average follow‐up period was 22.5 months (18.5, 23.9, and 21.2 months, respectively) and radiographic unions were observed at an average of 19.6 weeks (range, 12–28 weeks). The patients were evaluated immediately after surgery, as well as 6 weeks, 3 months, 6 months, 1 year, and 2 years postoperatively. Of the 49 patients, 38 had good reduction qualities (75.5%), 9 acceptable (18.3%), and 3 poor (6.1%). Radiographic union was confirmed in all fractures at an average of 19.6 weeks (range, 12–28 weeks). The mean Harris hip score was 84.9 (range, 65–99): excellent in 9 patients (18.36%), good in 30 (61.22%), medium in 8 (16.32%), and poor in 2 (4.08%). Slight persistent pain occurred in 3 patients, but these patients could still walk with the help of a cane. Two patients had symptoms of excessive telescoping. Eight patients experienced postoperative medical complications, mainly pneumonia and urinary tract infection.

Conclusion

Based on the clinical and radiological outcomes, the PFNA‐II devices provide strong rotational stability and excellent clinical prognosis, and are an appropriate treatment option for basicervical proximal femoral fracture in elderly patients.

Outcomes of Combined Neck and Trochanter Fractures of the Femur Treated with Cephallomedullary Nail in Elderly

Purpose

Proximal femur fractures are classified into intracapsular neck fractures and extracapsular trochanteric fractures, and several related treatment recommendations in elderly patients have already been introduced. Importantly, we have observed cases of combined intra and extracapsular fractures (i.e., ipsilateral neck and trochanter fractures). The purpose of this study is to report the outcomes of combined neck and trochanter fractures of the femur treated with cephalomedullary nail (CMN) in elderly patients.

Materials and Methods

From January 2010 to December 2014, 410 patients with proximal femoral fractures were fixed using CMN; among this group, 37 patients with combined neck and trochanter fractures were identified. Two of these patients died fewer than three months after injury and another two did not return for follow-up. Thirty-three patients were included and reviewed retrospectively in this study.

Results

All patients were injured by simple fall. Bone union was obtained in 28 of 33 patients. Of the five patients who failed treatment, three experienced implant penetration through head (cut-through and cut-out), one had breakage of CMN and the last one had a loosening of internal fixation device with persistent non-union at final follow-up. The former four patients underwent hip replacement surgery and the latter refused surgery because he had low demand in daily life and many medical problems.

Conclusion

Eighty-five percent of elderly patients with combined neck and trochanter fractures of the femur treated with CMN achieved bone union; these complex fractures require more accurate reduction than usual extra-articular intertrochanteric fractures.

Treatment of basicervical femoral neck fractures with proximal femoral nail antirotation

Objective

A basicervical femoral neck fracture, which is located at the junction between the femoral neck and intertrochanteric region, is a rare type of fracture. The treatment effects for this type of fracture vary. The present retrospective study was performed to evaluate the clinical and radiological outcomes of proximal femoral nail antirotation and illustrate its effect on improving the clinical prognosis of basicervical femoral neck fractures.

Methods

Fourteen patients with two-part basicervical fractures underwent treatment with proximal femoral nail antirotation.

Results

The treatment exhibited a good effect on decreasing complications such as femoral neck shortening and screw protrusion. Improvements were also noted in the Harris hip score and other clinical prognostic factors. The patients were satisfied with the prognosis, although not all of them returned to their preinjury level of occupation or daily activities.

Conclusion

This research provides clinical data to support the treatment of basicervical femoral neck fractures with proximal femoral nail antirotation and contributes to our understanding of treatment selection in the clinical setting. Selection of the optimal fixation method and subsequent conservative rehabilitation plan will benefit patients with basicervical femoral neck fractures.

Risk factors of fixation failure in basicervical femoral neck fracture: Which device is optimal for fixation?

BACKGROUND

Basicervical femur neck fracture (FNF) is a rare type of fracture, and is associated with increased risk of fixation failure due to its inherent instability. The purpose of this study was (1) to investigate the incidence of fixation failure and (2) to determine risk factors for fixation failure in basicervical FNF after internal fixation.

METHODS

To identify basicervical FNF with a minimum of 12 months follow-up, we retrospectively reviewed records of 3217 patients who underwent hip fracture surgery from May 2003 to March 2016. Among the identified 77 patients with basicervical FNF, 69 patients were followed up for at least 12 months. We evaluated the rate of collapse of fracture site and reoperation due to fixation failure. We performed a multivariable analysis to determine risk factors associated with fracture site collapse and fixation failure.

RESULTS

Among the 69 patients with basicervical FNF, 17 (24.6%) showed collapse of fracture site, and 6 (8.6%) underwent conversion to arthroplasty because of fixation failure. In the multivariable analysis, use of extramedullary plating with a sliding hip screw was an independent significant risk factor for both collapse of fracture site (odds ratio 6.84; 95% confidence interval 1.91-24.5, p = 0.003) and fixation failure (odds ratio 12.2; 95% confidence interval 1.08-137.7, p = 0.042).

CONCLUSIONS

Basicervical FNF treated with extramedullary plate with a sliding hip screw is more likely to fail than that treated with intramedullary nail with a helical blade. Our results suggested that intramedullary nail with a helical blade is more recommended for basicervical FNF compared with extramedullary plate with a sliding hip screw.

LEVEL OF EVIDENCE

III, Retrospective cohort study.