Closed reduction, internal fixation with quadratus femoris muscle pedicle bone grafting in displaced femoral neck fracture

Background:

Management of femoral neck fracture is still considered as an unsolved problem. It is more evident in displaced fractures where this fracture is considered as some sort of vascular insult to the head of the femur. We have used closed reduction, internal fixation and quadratus femoris muscle pedicle bone grafting in fresh displaced femoral neck fractures.

Materials and Methods:

From April 1996 to December 2004 we operated 73 consecutive patients of displaced femoral neck fracture in the age group of 24 to 81 years, mean age being 54.6 years. The patients were operated within one week of injury, the mean delay being 3.6 days. Closed reduction internal fixation along with quadratus femoris muscle pedicle bone grafting was done in all cases. They were followed up for an average period of 5.6 years (range 2-11 years).

Results:

Results were assessed according to modified Harris Hip Scoring system and found to be excellent in 53, good in 12, fair in six and poor in two patients. Bony union occurred in 68 cases, no patient developed avascular necrosis (AVN) till date.

Conclusion:

For fresh displaced femoral neck fracture in physiologically active patients closed reduction, internal fixation and quadratus femoris muscle pedicle bone grafting is a suitable option to secure union and prevent development of AVN.     

An orthopedic surgeon survey on the treatment of displaced femoral neck fracture: opposing views

Objective

To examine the reasons for practice variation in the treatment of displaced femoral neck fractures.

Design

A survey, asking surgeons to choose either hemiarthroplasty or internal fixation for 2 different female patients with a displaced femoral neck fracture.

Setting

The Canadian Orthopaedic Association Meeting, Halifax, May 1995.

Patients

The scenario in the first patient was of an independent 70-year-old woman with no pre-existing medical conditions. The scenario in the second patient was of a housebound 84-year-old woman with co-morbidity.

Main outcome measures

Proportion of surgeons choosing either hemiarthroplasty or internal fixation for each case scenario. Distribution of reasons to explain the treatment decision.

Results

Ninety-nine surgeons responded. For the case of the 70-year-old woman, 47% chose hemiarthroplasty and 53% chose internal fixation (p = 0.60), and for the 84-year-old woman, 96% chose hemiarthroplasty. These findings were consistent within the subgroups of teaching surgeons and community practice surgeons. Surgeons with 10 years or less of practice tended to favour hemiarthroplasty whereas those with more than 15 years’ practice favoured internal fixation. Important reasons for treatment choice were avoidance of reoperation in the hemiarthroplasty group (85%) and better hip function in the fixation group (83%), durability (83%) and ease of revision (77%).

Conclusion

The surgeon’s interpretation of the importance of reoperation and function underlies the differences in treatment decision regarding the management of femoral neck fractures in elderly patients.     

Unstable recent intracapsular femoral neck fractures in young adults: Osteosynthesis and primary valgus osteotomy using broad dynamic compression plate

Background:

Displaced intracapsular femoral neck fractures continue to be a difficult problem to treat. Various treatment modalities and their modifications have been proposed to improve the outcome. Osteosynthesis and primary valgus angulation osteotomy is one of them. Technique and outcome in a consecutive series of recent intracapsular femoral neck fractures in young adults, from a single center, is presented.

Materials and Methods:

Fifty-five patients of recent (<3 weeks old) displaced intracapsular fracture neck femur (Garden III and IV, Pauwels III, with or without comminution) in the age group 20-50 years (mean 35.4±10.4 years) were subjected to osteosynthesis and primary valgus intertrochanteric osteotomy using contoured broad dynamic compression plate (DCP). The patients were followed up from two to six years (mean 4.6 years).

Results:

Fifty-one fractures united by six months of the index procedure (92.7% union range). Avascular necrosis (AVN) developed in six patients (11%). The other complications were shortening (six), coxa vara (two), infection (two) and delayed union at osteotomy site (one). Excellent results were achieved in 48, good/fair in four and poor in three patients.

Conclusion:

Osteosynthesis with cancellous screw and primary valgus intertrochanteric osteotomy stabilized by a contoured broad DCP is a simple, easy to perform, biological treatment. Failure in a particular case can be treated with any appropriate second procedure.

Level of Evidence:

IV     

Clinical outcome after undisplaced femoral neck fractures

Background and purpose

Little attention has been paid to undisplaced femoral neck fractures. By using data from the Norwegian Hip Fracture Register, we investigated the risk of reoperation and the clinical outcome after treatment of these fractures in patients over 60 years of age.

Methods

Data on 4,468 patients with undisplaced femoral neck fractures who were operated with screw osteosynthesis were compared to those from 10,289 patients with displaced femoral neck fractures treated with screw osteosynthesis (n = 3,389) or bipolar hemiarthroplasty (n = 6,900). The evaluation was based on number of reoperations and patient assessment at 4 and 12 months of follow-up.

Results

The 1-year implant survival was 89% after screw fixation for undisplaced fractures, 79% after screw fixation for displaced fractures, and 97% after hemiarthroplasty for displaced fractures. Patients with displaced fractures who were operated with internal fixation had a higher risk of reoperation (RR = 1.9, CI: 1.7–2.2), reported more pain, were less satisfied, and had lower quality of life than patients with undisplaced fractures treated with internal fixation (p < 0.05). Patients with displaced fractures who were operated with hemiarthroplasty had a lower risk of reoperation than patients with undisplaced fractures who were operated with internal fixation (RR = 0.32, CI: 0.27–0.38). Furthermore, they had the lowest degree of pain, were most satisfied, and reported the highest quality of life.

Interpretation

Interpretation The differences in clinical outcome found were less than what is considered to be of clinical importance. The results support the use of screw osteosynthesis for undisplaced femoral neck fractures in elderly patients, although even better results were obtained in the hemiarthroplasty group in patients with displaced fractures.Each year, approximately 9,000 patients are operated for hip fractures in Norway. 19% are undisplaced femoral neck fractures (Garden 1 and 2) and 38% are displaced (Gjertsen et al. 2008). The treatment of displaced fractures has been investigated extensively, and some recent reports have shown better clinical outcome after hemiarthroplasty than after screw fixation (Rogmark et al. 2002, Frihagen et al. 2007, Gjertsen et al. 2010). Less has been published on the treatment of undisplaced fractures. Some authors advocate internal screw fixation as being the best treatment, even though a high rate of reoperations has been reported (Conn and Parker 2004, Bjorgul and Reikeras 2007, Parker et al. 2008). A recent study found poor outcome in many patients after treatment of undisplaced fractures (Rogmark et al. 2009).In Norway, there are no national guidelines for the treatment of hip fractures. The standard treatment for undisplaced fractures has been internal fixation with 2 screws or pins (94% of fractures) (Gjertsen et al. 2008). In the present study, we wanted to investigate the results after undisplaced femoral neck fractures, as reported to the Norwegian Hip Fracture Register. Risk of reoperation, pain, patient satisfaction, and quality of life were used as outcome measures. Since the undisplaced fractures were almost exclusively treated with internal fixation, patients with displaced femoral neck fractures treated with screw osteosynthesis or hemiarthroplasty were used as reference groups when analyzing the results.     

Delayed fixation of displaced type II and III pediatric femoral neck fractures

Background:

Time from injury to fixation of femoral neck fractures has been postulated as a vital determinant for rate of complications; however, no prospective study is available in the English literature. Delay, unfortunately, is inevitable in developing countries. The aim of the present study is to retrospectively review the outcome after delayed fixation of displaced type II and III femoral neck fractures in children.

Materials and Methods:

Using a standard assessment chart, we retrospectively reviewed medical records of all pediatric patients having femoral neck fractures presenting to our institution from June 1999 to May 2006. Inclusion criteria were children between 5 and 15 years of age sustaining displaced Delbet type II and III femoral neck fractures having a complete follow-up of at least 2 years. Patients with known metabolic disease, poliomyelitis or cerebral palsy, were excluded from the study. After application of inclusion and exclusion criteria, 22 patients having 22 fractures (13 type II and 9 type III) were studied. Surgery could be performed after a mean delay of 11.22 days (ranging from 2 to 21 days). Closed reduction was achieved in 14 cases and 8 cases required open reduction through anterolateral approach.

Result:

Osteonecrosis was noted in eight patients (36.37%) who included two of nine patients (22.22%) operated in the first week, three of eight patients (37.51%) operated in the second week, and three of five patients (60%) operated in the third week of injury. Nonunion was seen in four (18.18%) cases, and two of them were associated with failure of implants. One was treated by valgus osteotomy and the other by Meyer''s procedure. Fractures united in both children but the latter developed avascular necrosis. Functional results, as assessed using Ratliff''s criteria, were good in 14 (63.63%), fair in 2 (9%), and poor in 6 (27.27%) patients.

Conclusion:

Delay in fixation, type of fracture, and ability to achieve and maintain reduction are factors primarily responsible for the outcome. We also found that delay after the first week further adversely affects the outcome.     

Computed tomographic evaluation of the proximal femur: A predictive classification in displaced femoral neck fracture management

Background:

Femoral neck fracture is truly an enigma due to the high incidence of avascular necrosis and nonunion. Different methods have been described to determine the size of the femoral head fragment, as a small head has been said to be associated with poor outcome and nonunion due to inadequate implant purchase in the proximal fragment. These methods were two dimensional and were affected by radiography techniques, therefore did not determine true head size. Computed tomography (CT) is an important option to measure true head size as images can be obtained in three dimensions. Henceforth, we subjected patients to CT scan of hip in cases with displaced fracture neck of femur. The study aims to define the term small head or inadequate size femoral head” objectively for its prognostic significance.

Materials and Methods:

70 cases of displaced femoral neck fractures underwent CT scan preoperatively for proximal femoral geometric measurements of both hips. Dual energy X-ray absorptiometry scan was done in all cases. Patients were treated with either intertrochanteric osteotomy or lag screw osteosynthesis based on the size of the head fragment on plain radiographs.

Results:

The average femoral head fragment volume was 57 cu cm (range 28.3-84.91 cu cm; standard deviation 14 cu cm). Proximal fragment volume of >43 cu cm was termed adequate size (type I) and of ≤43 cu cm as small femoral head (type II). Fractures which united (n = 54) had a relatively large average head size (59 cu cm) when compared to fractures that did not (n = 16), which had a small average head size (49 cu cm) and this difference was statistically significant. In type I fractures union rate was comparable in both osteotomy and lag screw groups (P > 0.05). Lag screw fixation failed invariably, while osteotomy showed good results in type II fractures (P < 0.05).

Conclusion:

Computed tomography scan of the proximal femur is advisable for measuring true size of head fragment. An objective classification based on the femoral head size (type I and type II) is proposed. Osteosynthesis should be the preferred method of treatment in type I and osteotomy or prosthetic replacement is the method of choice for type II femoral neck fractures.     

Large diameter metal on metal total hip replacement for femoral neck fractures with neurological conditions: A retrospective assessment

Background:

Patients with Parkinson''s disease and poliomyelitis can have a femoral neck fracture; yet, the optimal methods of treatment for these hips remains controversial. Many constrained or semi-constrained prostheses, using constrained liners (CLs) with a locking mechanism to capture the femoral head, were used to treat femoral neck fractures in patients with neurological disorders. We retrospectively studied a group of patients with Parkinson''s disease and poliomyelitis who sustained femoral neck fractures and were treated by total hip arthroplasty using an L-MoM prosthesis.

Materials and Methods:

We retrospectively reviewed 12 hips in 12 patients who underwent large-diameter metal-on-metal (L-MoM) total hip replacement between May 2007 and October 2009. Eight of the 12 patients (8 hips; 66.7%) had Parkinson''s disease and 4 patients (4 hips; 33.3%) were affected with poliomyelitis.

Results:

The followup time was 5.2 years (range 3.6-6.0 years). At the latest followup, all the patients showed satisfactory clinical and radiographic results, with pain relief. No complications, such as dislocation or aseptic loosening occurred.

Conclusion:

We believe the use of L-MoM can diminish the rate of instability or dislocation, after operation. The L-MoM is an option for patients with Parkinson''s disease and poliomyelitis with femoral neck fracture.     

Augmented osteosynthesis with tensor fascia latae muscle pedicle bone grafting in neglected femoral neck fracture

Background:

Neglected intracapsular femoral neck fracture in young patients may fail to unite because of the excessive shearing strain at the fracture site and it is a surgical challenge to any orthopedic surgeon. The problem is compounded by resorption of the femoral neck and avascular necrosis (AVN) of femoral head. There is no satisfactory solution available in the management of femoral neck fracture as far as the union of the fracture and AVN of femoral head are concerned. Muscle pedicle bone grafting has been advocated to provide additional blood supply to the femoral head. We report a retrospective analysis of 48 cases of neglected femoral neck fracture treated by internal fixation and tensor fascia latae based muscle pedicle bone grafting.

Materials and Methods:

48 patients with femoral neck fractures with age varied from 20 to 53 years (average age 32.9 years) with male to female ratio of 2:1 were enrolled. All fractures were more than 3 weeks old with mean delay being 86 days (22–150 days). Open reduction and internal fixation along with tensor fascia latae muscle pedicle bone grafting was done in all cases. It was supplemented by multiple drilling and cortico-cancellous bone grafting. Fracture fixation was done with three parallel 6.5-mm AO cannulated cancellous lag screws and the graft fixed with a 4-mm cancellous screw to provide a secure fixation. During the followup period of 2-6.8 years (average 4.4 years) the results were assessed clinically by modified Harris hip scoring system and radiologically by the evidence of signs of fracture union.

Results:

Union was achieved in 41/48 (85.41%) cases which were followed for an average period of 4.4 years (2–6.8 years) with good functional results and ability to squat and sit cross-legged. Results were assessed according to modified Harris Hip Scoring system and found to be excellent in 19, good in 22, fair in 5, and poor in 2 patients. Complications were nonunion, (n=3) avascular necrosis (n=2), and coxa vara deformity (n=2).

Conclusion:

Internal fixation with muscle pedicle bone grafting is a suitable option to secure union in neglected femoral neck fractures in physiologically active patients with late presentation.     

Glenoid fossa fractures: Outcome of operative and nonoperative treatment

Background:

Glenoid fossa fractures are rare injuries having a prevalence of 0.1%. These fractures may be managed operatively if substantially displaced. However, several fractures of glenoid fossa are managed nonoperatively, even if displaced, due to high incidence of associated injuries which may render patient unfit to undergo major orthopaedic surgery. There is a relative paucity of articles reporting on outcome of treatment of glenoid fossa fractures. We present our experience of treating these injuries over past decade with operative and nonoperative methods.

Materials and Methods:

21 patients of glenoid fossa fractures were included in this series with 14 males and 7 females. Patients with displacement of >5 mm who were fit to undergo surgery within 3 weeks of injury were operated using a posterior Judet''s approach. Overall 8 patients with displaced fractures were operated (Group A) while 9 patients with displaced fractures (Group B) and 4 patients with undisplaced fractures (Group C) were managed nonoperatively.

Results:

The mean age and followup period in this series was 29 years and 7.3 years respectively. In group A, average constant score was 87.25. The least constant score was observed for group B (58.55) while group C had an average constant score of 86. Brachial plexus injury and fracture-dislocations had poorer outcome.

Conclusion:

Operative treatment for displaced glenoid fractures is a viable option at centers equipped to handle critically ill patients and subset of patients with fracture-dislocation as opposed to fracture alone should always be treated operatively due to persistent loss of function.     

Low bone mineral density is not related to failure in femoral neck fracture patients treated with internal fixation

Background and purpose

Internal fixation (IF) in femoral neck fractures has high reoperation rates and some predictors of failure are known, such as age, quality of reduction, and implant positioning. Finding new predictors of failure is an ongoing process, and in this study we evaluated the importance of low bone mineral density (BMD).

Patients and methods

140 consecutive patients (105 females, median age 80) treated with IF had a dual-energy X-ray absorptiometry (DXA) scan of the hip performed median 80 days after treatment. The patients’ radiographs were evaluated for fracture displacement, implant positioning, and quality of reduction. From a questionnaire completed during admission, 2 variables for comorbidity and walking disability were chosen.Primary outcome was low hip BMD (amount of mineral matter per square centimeter of hip bone) compared to hip failure (resection, arthroplasty, or new hip fracture). A stratified Cox regression model on fracture displacement was applied and adjusted for age, sex, quality of reduction, implant positioning, comorbidity, and walking disability.

Results

49 patients had a T-score below –2.5 (standard deviation from the young normal reference mean) and 70 patients had a failure. The failure rate after 2 years was 22% (95% CI: 12–39) for the undisplaced fractures and 66% (CI: 56–76) for the displaced fractures. Cox regression showed no association between low hip BMD and failure. For the covariates, only implant positioning showed an association with failure.

Interpretation

We found no statistically significant association between low hip BMD and fixation failure in femoral neck fracture patients treated with IF.Internal fixation (IF) for femoral neck fracture has many advantages such as minimal blood loss, short operating time, and low infection rate (Rogmark and Johnell 2006). The trend is, however, to treat displaced fractures with hemiarthroplasty due to a high reoperation rate of IF in comparison to arthroplasty (40% vs. 11%), and also due to better functional outcome (Parker and Gurusamy 2006). The high reoperation rate is mainly due to early failure of fixation.There are several factors that can lead to an increased risk of failure. The most important is fracture displacement, which leads to 11% failure in undisplaced fractures and 40% failure in displaced fractures (Parker and Gurusamy 2006, Gjertsen et al. 2011). There is an increased risk of non-union with older age (Parker et al. 2007), poor quality of reduction (Schep et al. 2004, Heetveld et al. 2007), and poor implant positioning (Schep et al. 2004). Low BMD may be another predictor of failure. Low BMD is a well-defined risk factor for hip fracture (Kanis et al. 2008) and experimentally, several studies have shown that low BMD affects the strength of osteosynthesis (Sjostedt et al. 1994, Bonnaire et al. 2005). In addition, low BMD appears to delay fracture healing but the association between low BMD and failure in clinical studies is more uncertain (Giannoudis et al. 2007). Karlsson et al. (1996) and Heetveld et al. (2005) found no association between low BMD and failure, but the known predictors of failure were not adjusted for in these studies. The only study that used all the known potential confounders in the analysis was Spangler et al. (2001). However, this study was retrospective and used the osteoporosis diagnosis from a register. We evaluated the effects of low BMD on failure of femoral neck fractures treated with IF while adjusting for known predictors of failure.     

The direct anterior approach in hemiarthroplasty for displaced femoral neck fractures

Purpose

Hip replacement is the most common treatment for displaced femoral neck fractures in the elderly, and minimally invasive surgery is popular in the field of orthopaedic surgery. This study evaluated the outcome of monopolar hemiarthroplasty by the direct anterior approach over a postoperative period up to 2.5 years.

Methods

A total of 86 patients with displaced femoral neck fractures were included (mean age of 86.5 years). Surviving patients were reviewed three months (retrospectively) and one to 2.5 years (prospectively) after surgery. One-year mortality was 36 %.

Results

For all stems, implant positioning with respect to stem alignment, restoration of leg length and femoral offset was correct. Acetabular protrusion was observed in 55 % of the patients one to 2.5 years postoperatively. Subsidence and intraoperative periprosthetic fractures occurred in three patients (3 %) each. All revision stems for postoperative periprosthetic fractures could be implanted using the initial surgical technique without extension of the previous approach. The mean Harris hip score was 85 points at the one to 2.5-year follow-up; 85 % of the patients were satisfied with their hip and 57 % returned to their preoperative level of mobility.

Conclusion

Based on these findings, hemiarthroplasty for hip fractures can be performed safely and effectively via the direct anterior approach with good functional outcome and high patient satisfaction.     

Cementless hemiarthroplasty for femoral neck fractures in elderly patients

Objectives:

The use of cement is associated with increased morbidity and mortality rate in elderly patients, hence cementless hemiarthroplasty is suggested. We evaluated the results of cementless hemiarthroplasty for femoral neck fractures in elderly patients with high-risk clinical problems.

Materials and Methods:

Forty-eight patients (29 females, 19 males) with a mean age of 88 years (range: 78 to 102 years). having femoral neck fractures were treated with the use of cementless hemiarthroplasty. Porous-coated femoral stems were used in 30 patients (62%) and modular type femoral revision stems in 18 patients (38%). Bipolar femoral heads were used in all patients. Radiological follow-up after operation was done at the one, three, six months and annually.

Results:

The mean follow-up period was 4.2 years (range: 18 months to eight years). None of the patients died during hospitalization. Medical complications occurred in six patients (12%) within the follow-up period and four patients (8%) died within this period. Only two hips were converted to total hip arthroplasty due to acetabular erosion. Femoral revision was planned for one patient with a subsidence of > 3 mm. None of the patients had acetabular protrusion or heterotopic ossification. The mean Harris-hip score was 84 (range: 52 to 92). Dislocation occured in one patient (2%).

Conclusion:

Cementless hemiarthroplasty is a suitable method of treatment for femoral neck fractures in elderly patients with high-risk clinical problems especially of a cardiopulmonary nature. This method decreases the risk of hypotension and fat embolism associated with cemented hemiarthroplasty.     

Dual mobility cup reduces dislocation and re-operation when used to treat displaced femoral neck fractures

Purpose

Total hip arthroplasty (THA) as primary treatment for displaced femoral neck fractures is controversial as THA is associated with higher rates of dislocation but lower rates of re-operation compared to hemiarthroplasty (HA). A dual mobility cup (DMC) design is associated with lower dislocation and re-operation rates in elective surgery. Is this also the case when used to treat displaced femoral neck fractures? The aim of this study is to compare rates of dislocation and re-operation of any kind following treatment for displaced femoral neck fractures with either bipolar HA or THA with DMC.

Methods

Two consecutive groups of patients treated for displaced femoral neck fractures at the Regional Hospital in Viborg in Denmark were included. In 2007–2008 171 patients (mean age 84.1 years) were treated with bipolar HA. In 2009–2010 175 patients (mean age 75.2 years) were treated with THA with DMC. Data regarding rates of dislocation and re-operation were obtained by retrospective review of medical records.

Results

We found a statistically significant difference regarding rates of dislocation and re-operation of any kind in favour of THA with DMC. Dislocation occurred in 25/171 patients [95 % confidence interval (CI) 9.3–19.9 %] treated with bipolar HA and 8/175 patients (95 % CI 1.5–7.7 %) treated with THA with DMC (p = 0.002). Re-operations were required in 32/171 patients (95 % CI 12.9–24.6 %) treated with bipolar HA and 16/175 patients (95 % CI 4.8–13.4 %) treated with THA with DMC (p = 0.01).

Conclusions

Our findings indicate that THA with DMC is superior to bipolar HA following treatment for displaced femoral neck fractures in regard to rates of dislocation and re-operation.     

Results of titanium locking plate and stainless steel cerclage wire combination in femoral fractures

Background:

Some in vitro studies warn combining different metals in orthopedic surgery. The aim of this study is to determine the impact of combining titanium and stainless steel on bone healing and the clinical course of patients undergoing internal fixation of femoral fractures.

Materials and Methods:

69 patients with femoral fractures had polyaxial locking plate osteosynthesis. The locking plate was made of a titanium alloy. Two different cohorts were defined: (a) sole plating and (b) additional stainless steel cerclage wiring. Postoperative radiographs and clinical followup were performed at 6 weeks, 3 months and 12 months.

Results:

Cohorts A and B had 36 and 33 patients, respectively. Patient demographics and comorbidities were similar in both groups. In two cases in cohort A, surgical revision was necessary. No complication could be attributed to the combination of titanium and stainless steel.

Conclusion:

The combination of stainless steel cerclage wires and titanium plates does not compromise fracture healing or the postoperative clinical course.     

Post-traumatic coxa vara in children following screw fixation of the femoral neck

Background and purpose

The rare displaced fractures of the femoral neck in children need accurate reduction and rigid fixation. The implants commonly used for internal fixation in children are pins or screws. We evaluated the long-term outcome in children who sustained fractures of the proximal femur that were treated by screw fixation.

Patients and methods

All 22 children (mean age 12 (5–16) years) with fractures of the femoral neck that were treated with screw fixation (mean 2.4 (1–3) screws) at our department between 1990 and 2006 were evaluated. For measurement of outcome, the Harris hip score (HHS) was used and the development of post-traumatic coxa vara was assessed from the difference in the neck-shaft angle postoperatively and at the latest follow-up examination, after mean 4 (2–15) years.

Results

A loss of reduction was observed in 12 patients. There was a statistically significant correlation between the HHS and the changes in the neck-shaft angle.

Interpretation

Loss of reduction was found in more than half of the children. Screw fixation cannot be recommended for the treatment of femoral neck fractures in children due to a substantial number of post-traumatic coxa vara.     

Mortality and Revision Surgery Are Increased in Patients With Parkinson’s Disease and Fractures of the Femoral Neck

Background

Patients with Parkinson’s disease are at increased risk for falls and associated hip fractures as a result of tremor, bradykinesia, rigidity, and postural instability. The available literature is limited and conflicting regarding the optimal surgical treatment and risk for postoperative complications and mortality in this unique patient population.

Questions/purposes

We asked: (1) Is there a difference in mortality after surgical treatment of hip fractures in patients with Parkinson’s disease compared with similar patients with hip fractures without Parkinson’s disease? (2) Does Parkinson’s disease lead to a higher rate of reoperation after operative treatment of femoral neck fractures? (3) Does Parkinson’s disease lead to a higher rate of dislocation after hemiarthroplasty for displaced femoral neck fractures, and (4) does the operative approach affect dislocation rates?

Methods

In this case-controlled study, we retrospectively reviewed 141 patients with a diagnosis of Parkinson’s disease and a fracture of the femoral neck. Each patient with Parkinson’s disease was matched with two control patients (n = 282) without Parkinson’s disease stratified by age, sex, American Society of Anesthesiologists classification, and fracture type (nondisplaced/displaced). Clinical outcomes included mortality after surgical intervention, rate of reoperation, dislocation events after hemiarthroplasty, and the rate of failure after internal fixation for nondisplaced fractures.

Results

The median survival time of the patients with Parkinson’s disease after fracture was 31 months (95% CI, 25–37 months) compared with 45 months (95% CI, 39–50 months) in our control group (p = 0.007). The rate of reoperation for displaced and nondisplaced fractures was higher in the Parkinson’s disease group compared with the control group (11% versus 4%; p = 0.005). Failure of fixation for patients treated with internal fixation of nondisplaced femoral neck fractures was significantly higher in the Parkinson’s disease group compared with our control group (22% versus 5%; p = 0.01). Dislocation rates after hemiarthroplasty were significantly higher in the Parkinson’s disease group compared with the control group (8% versus 1%; p = 0.003). Patients treated with a hemiarthroplasty through an anterolateral approach had a significantly lower dislocation rate compared with those treated with a posterior approach (2% versus 15%; p = 0.002).

Conclusions

Parkinson’s disease is an independent predictor of mortality after femoral neck fracture and is associated with an increased rate of dislocation, revision surgery, and failure of internal fixation. Although patients with Parkinson’s disease with a nondisplaced or valgus impacted femoral neck fracture may be treated with internal fixation, they are at significantly higher risk of failure of fixation compared with patients without Parkinson’s disease. Use of a hemiarthroplasty through an anterolateral approach may reduce the likelihood of requiring a revision operation.

Level of Evidence

Level III, therapeutic study.     

Plate versus titanium elastic nail in treatment of displaced midshaft clavicle fractures: A comparative study

Background:

With changing trends in treatment of displaced midshaft clavicle fractures (DMCF), plating remains the standard procedure for fixation. An attracting alternative method of fixation is the titanium elastic nailing (TEN). However, prospective randomized studies comparing the two methods of fixation are lacking. We assessed the effectiveness of minimally invasive antegrade TEN and plating technique for the treatment of DMCF.

Materials and Methods:

80 unilateral displaced midclavicular fractures operated between October 2010 and May 2013 were included in study. This prospective comparative study was approved by the local ethical committee. Followups were at 2^nd and 6^th weeks and subsequently at 3, 6, 12, 18 and 24 months postoperatively. Primary outcome was measured by the Constant score, union rate and difference in clavicular length after fracture union. Secondary outcome was measured by operative time, intraoperative blood loss, wound size, cosmetic results and complications.

Results:

During analysis, we had 37 patients in the plate group and 34 patients in the TEN group. There was no significant difference in Constant scores between the two groups. However, faster fracture union, lesser operative time, lesser blood loss, easier implant removal and fewer complications were noted in the TEN group.

Conclusion:

The use of minimally invasive antegrade TEN for fixation of displaced midshaft clavicle fractures is recommended in view of faster fracture union, lesser morbidity, better cosmetic results, easier implant removal and fewer complications; although for comminuted fractures plating remains the procedure of choice.     

Results of triple muscle (sartorius,tensor fascia latae and part of gluteus medius) pedicle bone grafting in neglected femoral neck fracture in physiologically active patients

Background:

Femoral neck fractures are notorious for complications like avascular necrosis and nonunion. In developing countries, various factors such as illiteracy, low socioeconomic status, ignorance are responsible for the delay in surgery. Neglected fracture neck femur always poses a formidable challenge. The purpose of this study was to evaluate the results of triple muscle pedicle bone grafting using sartorius, tensor fasciae latae and part of gluteus medius in neglected femoral neck fracture.

Materials and Methods:

This is a retrospective study with medical record of 50 patients, who were operated by open reduction, internal fixation along with muscle pedicle bone grafting by the anterior approach. After open reduction, two to three cancellous screws (6.5 mm) were used for internal fixation in all cases. A bony chunk of the whole anterior superior iliac spine of 1 cm thickness, 1 cm width and 4.5 cm length, taken from the iliac crest comprised of muscle pedicle of sartorius, tensor fascia latae and part of gluteus medius. Then the graft with all three muscles mobilized and put in the trough made over the anterior or anterosuperior aspect of the femoral head. The graft was fixed with one or two 4.5 mm self-tapping cortical screw in anterior to posterior direction.

Results:

14 patients were lost to followup. The results were based on 36 patients. We observed that in our series, there was union in 34, out of 36 (94.4%) patients. All patients were within the age group of 15-51 years (average 38 years) with displaced neglected femoral neck fracture of ≥30 days. Mean time taken for full clinicoradiological union was 14 weeks (range-10-24 weeks).

Conclusion:

Triple muscle pedicle bone grafting gives satisfactory results for neglected femoral neck fracture in physiologically active patients.     

Incidence of Radiographic Cam-Type Impingement in Young Patients (<50) After Femoral Neck Fracture Treated with Reduction and Internal Fixation

Background:

Cam-type femoral impingement is caused by structural abnormalities of the hip and is recognized as a cause of degenerative hip arthritis. Identifiable etiologies of this structural abnormality include congenital malformation, pediatric hip disease, and malunion of femoral neck fractures after internal fixation.

Purpose:

The purpose of this study was to determine the prevalence of radiographic impingement in healed Orthopaedic Trauma Association (OTA) type 31B fractures treated with reduction and internal fixation.

Methods:

Seventy OTA 31B hip fractures treated with internal fixation were identified from our institutional trauma database and radiographs were retrospectively reviewed for signs of impingement. Mean follow-up was 53 months after fracture. Alpha angle, Mose templates, and femoral head retroversion were the measurements used to determine impingement.

Results:

The overall prevalence of any sign of radiographic impingement was 75%. Alpha angle was elevated in 32 hips (46%), asphericity was present in 46 femoral heads (65%), and femoral head retroversion was present in 26 hips (37%). The rates were highest in displaced subcapital fractures (OTA 31B-3) with a 63% (13/19) prevalence of elevated alpha angle, 68% (14/19) prevalence of asphericity, and 47% (10/19) prevalence of retroversion.

Conclusions:

Prevalence of radiographic signs of impingement in this population is higher than expected based on population-based controls. Surgeons must be vigilant about reduction and fixation of femoral neck fractures. Malunion should be recognized as early intervention may be beneficial in improving long-term outcomes.     

Outcome of Gartland type II and type III supracondylar fractures treated by Blount's technique

Background:

According to some orthopedic surgeons, almost all supracondylar humerus fractures should be treated operatively by reduction and pinning. While according to others, closed reduction and immobolization should be used for Gartland type II and some type III fractures. However, the limit of this technique remains unclear. We present 74 patients with displaced extension-type supracondylar fractures treated by closed reduction and immobilization with a collar sling fixed to a cast around the wrist. The purpose of the study is to give a more precise limitation of this technique.

Materials and Methods:

Retrospective data acquisition of 74 patients with a Gartland type II or type III fractures treated by closed reduction and immobilization (Blount''s technique) between January 2004 and December 2007 was done. The mean age was 6.3 years (range, 2–11). The mean time of follow-up was 6.5 months (range, 3–25). All open injuries and complex elbow fracture dislocations or T-condylar fractures were excluded from the study. All patients were evaluated with standardized anteroposterior and true lateral x-rays of the elbow, and Flynn criteria were used for functional assessment.

Results:

Gartland type II fractures had 94% good or excellent final results. Gartland type III fractures had 73% good or excellent final result. The Gartland type III outcome depended on the displacement. The fractures remained stable in 88% for the posterior displacement, and 58% for the posteromedial displacement. These displacements were mild. However, for the posterolaterally displaced fractures, only 36% were stable; 36% had a mild displacement and 27% had a major displacement.

Conclusion:

Pure posterior displacement is more stable than posteromedial displacement which is more stable than posterolaterally displaced fractures. This study suggests that Gartland type II and pure posterior or posteromedial displaced Gartland type III fractures can be treated by closed reduction and immobilization with success.