Treatment of the displaced femoral neck fractures: indications and limits of osteosynthesis

PURPOSE

Opinions about the optimal treatment of displaced femoral neck fractures in the elderly are still divided. The two main options are internal fixation and arthroplasty. The aim of our study was to determine the most adequate surgical procedure for displaced, Garden type III-IV femoral neck fractures: which patients should undergo an osteosynthesis or primary arthroplasty, with the least prospect of complications?

METHODS

We analyzed 489 femoral neck fractures treated by percutaneous osteosynthesis. We also compared the results of displaced fractures treated with primary arthroplasty versus secondary arthroplasty performed due to the failure of primary osteosynthesis.

RESULTS

The rate of redisplacement in the Garden type III group was 7.6%, and in the Garden type IV group, it was 25.5%, mainly in the case of subcapital fractures. Also, walking ability was examined 4 months after injury. In the ASA score II-III group, most of the patients were able to walk with or without walking aids, but in the case of ASA score IV, most of them were immobile or died during the hospital or posthospital phase. Our research also proved that, in cases of femoral neck fractures treated with primary arthroplasty, the complication rate is lower than after secondary arthroplasty due to failure of the primary osteosynthesis.

CONCLUSIONS

Based on our results, we recommend osteosynthesis in the case of Garden type III femoral neck fractures and, in turn, arthroplasty with respect to the high rate of early redisplacement in the case of Garden type IV fractures, especially in the case of subcapital fractures. For patients confined to a bed and in poor general condition (ASA score IV), the first choice treatment option is the minimally invasive percutaneous osteosynthesis.

Ischemia reperfusion injury of the skeletal muscle after selective deafferentation

The present study analyzes the effect of selective deafferentation on the reperfusion injury of the skeletal muscle when nociceptive sensory fibers of the left sciatic nerve are selectively damaged by capsaicin pretreatment in a rat model following tourniquet ischemia (ISC) applied for 30 min, 1 h, and 2 h on the left hind limb. The isometric tetanic contractile force of the extensor digitorum longus (EDL) muscle was measured after 1 h, and 1, 3, or 7 days of reperfusion. Contractile force of the damaged muscle was compared to the intact contralateral muscle. In another group, ISC was used without capsaicin pre-treatment. After 30 min of ISC, there was no difference between deafferented and non-pretreated groups. Following 1 h ISC, with the exception of 1 h reperfusion, the non-pretreated group produced stronger contractions than the deafferented group. After 2 h ISC, the contractile force of the deafferented muscle was significantly stronger compared to the non-deafferented muscle force at all reperfusion times. In conclusions, it was found that the absence of peptidergic sensory fibers after long-lasting (2 h) ischemia is beneficial in reperfusion injury, whereas the absence of vasodilator peptides has unfavorable effects if tissue damage is milder (after 1 h ischemia).

[Special epiphyseal injuries. 5 case examples]

In daily practice, the well-proved Salter-Harris-Rang epiphyseal injuries classification is used worldwide and in Hungary as well. Occasionally there are to be seen epiphyseal injuries which cannot be typed by this classification. The Ogden classification of epiphyseal injuries which enlarges the Salter-Harris-Rang classification with 6 subdivisions and 3 more subdivisions is very useful for the classification of such rare epiphyseal injuries. The authors focus one's attention on Ogden IIB type and Ogden VI type injuries on the basis of their own experience. Ogden IIB is often unstable and susceptible to shortening. In Ogden VI type ligamentous instability beside growing disturbance, caused by meta-epiphyseal bone bridge formation, can be seen. The comminuted growing plate injury caused by high energy direct trauma and healed without growing disturbance in their case, is missed in the Ogden classification. The proper classification is a necessary condition of adequate treatment. We recommend the Ogden classification of rare epiphyseal injuries.

[One-year follow-up experience in the rehabilitation of patients with femoral neck fractures]

Authors have followed 754 patients with hip fracture and have found that about 60 per cent of them are alive after one year; their functional state further improved between 4 months and 1 year, it cannot be however considered as satisfactory even after one year. Analysing the operations performed in femoral neck and trochanteric fractures it should be stated that the operative indications are generally adequate and the conditions of further improvement are defined. More significant improvement of the lasting results can be expected from a well organized rehabilitation.

[Osteosynthesis of femoral neck fractures by double-cannulated screws (preliminary report)]

Authors report on a new osteosynthesis based on the double nailing of femoral neck fracture and screwing, and developed from the "Uppsala" double screwing. The preliminaries of the double cannulated screwing method, its advantages, the experiences gained in 30 cases operated in one year and the early results are described.

[Problems of rehabilitation after femoral neck fractures in Hungary and possible solutions]

Authors examined the results of the 4 months rehabilitation of 753 cases of hip fractures treated in one year in their Institute. It was stated that a significant part of the patients had to be discharged too early. It is contributed to the inadequacy of the rehabilitation possibilities of the patients that 3/4 of those living after 4 months have complaints, only half of them can leave their flat, only 1/5 walks without a stick and 1/3 with one stick. On the basis of Swedish experiences they see the possibility of improving their results in a closer cooperation with the primary health care.

[Femoral neck fracture--selection of treatment method]

Authors followed for 4 months the life of 753 patients with femoral fractures of the hip and state, that with an extension of the operative indication the hospital mortality was decreased to the half during 15 years in spite of the further rise of the age. It is contributed first of all to the inadequacy of the rehabilitation that the later mortality is high and it is the double of that in the hospital: not more than 3 of 4 injured reaches the 4 months control.