空心髋螺钉固定髋关节内股骨颈骨折的X线透视导航手术

本文旨在介绍在X线透视导航下空心髋螺钉固定髋关节内股骨颈骨折的手术方法。发现X线透视导航可优化螺钉的固定位置和减少髋关节内股骨颈骨折固定术中X线的辐射。     

Patterns of osteocytic endothelial nitric oxide synthase expression in the femoral neck cortex: differences between cases of intracapsular hip fracture and controls

Evidence indicates that extensive amalgamation of adjacent resorbing osteons is responsible for destroying the microstructural integrity of the femoral neck’s inferior cortex in osteoporotic hip fracture. Such osteonal amalgamation is likely to involve a failure to limit excessive resorption, but its mechanistic basis remains enigmatic. Nitric oxide (NO) inhibits osteoclastic bone destruction, and in normal bone cells its generation by endothelial nitric oxide synthase (eNOS, the predominant bone isoform) is enhanced by mechanical stimuli and estrogen, which both protect against fracture. To determine whether eNOS expression in osteocytes reflects their proposed role in regulating remodeling, we have examined patterns of osteocyte eNOS immunolabeling in the femoral neck cortex of seven cases of hip fracture and seven controls (females aged 68–96 years). The density of eNOS⁺ cells (mm⁻²) was 53% lower in the inferior cortex of the fracture cases (p < 0.0004), but was similar in the superior cortex. eNOS⁺ osteocytes were, on average, 22% further from their nearest blood supply, than osteocytes in general (p < 0.0001) and the nearest eNOS⁺ osteocyte was 57% further from its nearest canal surface (p < 0.0001). This differential distribution of eNOS⁺ osteocytes was significantly more pronounced in the cortices of fracture cases (p < 0.0001). We conclude that the normal regional and osteonal pattern of eNOS expression by osteocytes is disrupted in hip fracture, particularly at sites that are loaded most by physical activity. These results suggest that eNOS⁺ osteocytes may normally act as sentinels confining resorption within single osteons. A reduction in their number, coupled to an increase in their remoteness from canal surfaces, may thus permit the irreversible merging of resorbing osteons, and thus contribute to the marked increase in the fragility of osteoporotic bone.     

Sclerostin and the regulation of bone formation: Effects in hip osteoarthritis and femoral neck fracture

Remodeling imbalance in the elderly femoral neck can result in thin cortices and porosity predisposing to hip fracture. Hip osteoarthritis protects against intracapsular hip fracture. By secreting sclerostin, osteocytes may inhibit Wnt signaling and reduce bone formation by osteoblasts. We hypothesised that differences in osteocytic sclerostin expression might account for differences in osteonal bone‐formation activity between controls and subjects with hip fracture or hip osteoarthritis. Using specific antibody staining, we determined the osteocytic expression of sclerostin within osteons of the femoral neck cortex in bone removed from subjects undergoing surgery for hip osteoarthritis (hOA: 5 males, 5 females, 49 to 92 years of age) or hip fracture fixation (FNF: 5 males, 5 females, 73 to 87 years of age) and controls (C: 5 males, 6 females, 61 to 90 years of age). Sclerostin expression and distances of each osteocyte to the canal surface and cement line were assessed for all osteonal osteocytes in 636 unremodeled osteons chosen from fields (～0.5 mm in diameter) with at least one canal staining for alkaline phosphatase (ALP), a marker of bone formation. In adjacent sections, ALP staining was used to classify basic multicellular unit (BMUs) as quiescent or actively forming bone (ALP⁺). The areal densities of scl^? and scl⁺ osteocytes (number of cells per unit area) in the BMU were inversely correlated and were strong determinants of ALP status in the BMU. In controls and hip fracture patients only, sclerostin‐negative osteocytes were closer to osteonal surfaces than positively stained cells. Osteon maturity (progress to closure) was strongly associated with the proportion of osteonal osteocytes expressing sclerostin, and sclerostin expression was the chief determinant of ALP status. hOA patients had 18% fewer osteocytes per unit bone area than controls, fewer osteocytes expressed sclerostin on average than in controls, but wide variation was seen between subjects. Thus, in most hOA patients, there was increased osteonal ALP staining and reduced sclerostin staining of osteocytes. In FNF patients, newly forming osteons were similar in this respect to hOA osteons, but with closure, there was a much sharper reduction in ALP staining that was only partly accounted for by the increased proportions of osteonal osteocytes staining positive for sclerostin. There was no evidence for a greater effect on ALP expression by osteocytes near the osteonal canal. In line with data from blocking antibody experiments, osteonal sclerostin appears to be a strong determinant of whether osteoblasts actively produce bone. In hOA, reduced sclerostin expression likely mediates increased osteoblastic activity in the intracapsular cortex. In FNF, full osteonal closure is postponed, with increased porosity, in part because the proportion of osteocytes expressing sclerostin increases sharply with osteonal maturation. © 2010 American Society for Bone and Mineral Research     

Evidence for reduced bone formation surface relative to bone resorption surface in female femoral fragility fracture patients

Fragility fractures, including neck of femur fractures, result from reductions in the amount, quality and architecture of bone. The aim of this study was to compare the cancellous bone structure, and static indices of bone turnover, in female patients, who had sustained fragility fracture at the femoral neck, with age-matched females without fragility fracture. Bone samples were taken from the intertrochanteric region of the proximal femur of female patients undergoing hip arthroplasty surgery for a subcapital fragility fracture of the femoral neck (#NOF) or from age-matched female control individuals at routine autopsy. Contiguous bone samples were analyzed for undecalcified histomorphometry and for mRNA expression. The histomorphometric data, which were normally distributed, indicated no difference between the mean values for any of the structural parameters in control and fracture samples. In particular, the bone volume (BV/TV) values were not different and did not change significantly with age in these cohorts of individuals aged > 65 years. The static indices of bone turnover, eroded surface (ES/BS) and osteoid surface (OS/BS), were positively correlated with age in the > 65-year-old control group (p < 0.055 and p < 0.03, respectively). The median values for these indices were not different between the fracture and control groups. However, both the median and the range of OS/BS values were increased for > 65-year-old controls compared with a group of younger females aged < 65 years, suggesting an increase in bone formation surface in older females in the proximal femur after 65 years of age. When the data were further interrogated, a reduction in the percentage osteoid surface to eroded surface quotient (OS/ES) was found for the fracture group compared with the age-matched control group suggesting a reduced adaptive modeling drift capability in the fracture group. In contiguous bone samples, increased median values for receptor activator of nuclear factor kappa β (RANK) and interleukin-6 (IL-6) mRNA expression were observed in the fracture group. Study of cultured human osteoblasts showed that recombinant human IL-6 (rhIL-6) inhibited osteoblast differentiation, as measured by an increase in the immature osteoblast marker, STRO-1 and concomitantly decreased expression of the osteoblast maturation marker, alkaline phosphatase. Importantly, cells cultured in the presence of IL-6 showed significantly less mineral deposition in vitro compared with control cultures. These data suggest that perturbations in bone formation surface, relative to resorption surface, are potentially important in producing bone in the proximal femur with increased propensity to fracture.     

Evidence for reduced bone formation surface relative to bone resorption surface in female femoral fragility fracture patients

Fragility fractures, including neck of femur fractures, result from reductions in the amount, quality and architecture of bone. The aim of this study was to compare the cancellous bone structure, and static indices of bone turnover, in female patients, who had sustained fragility fracture at the femoral neck, with age-matched females without fragility fracture. Bone samples were taken from the intertrochanteric region of the proximal femur of female patients undergoing hip arthroplasty surgery for a subcapital fragility fracture of the femoral neck (#NOF) or from age-matched female control individuals at routine autopsy. Contiguous bone samples were analyzed for undecalcified histomorphometry and for mRNA expression. The histomorphometric data, which were normally distributed, indicated no difference between the mean values for any of the structural parameters in control and fracture samples. In particular, the bone volume (BV/TV) values were not different and did not change significantly with age in these cohorts of individuals aged > 65 years. The static indices of bone turnover, eroded surface (ES/BS) and osteoid surface (OS/BS), were positively correlated with age in the > 65-year-old control group (p < 0.055 and p < 0.03, respectively). The median values for these indices were not different between the fracture and control groups. However, both the median and the range of OS/BS values were increased for > 65-year-old controls compared with a group of younger females aged < 65 years, suggesting an increase in bone formation surface in older females in the proximal femur after 65 years of age. When the data were further interrogated, a reduction in the percentage osteoid surface to eroded surface quotient (OS/ES) was found for the fracture group compared with the age-matched control group suggesting a reduced adaptive modeling drift capability in the fracture group. In contiguous bone samples, increased median values for receptor activator of nuclear factor kappa β (RANK) and interleukin-6 (IL-6) mRNA expression were observed in the fracture group. Study of cultured human osteoblasts showed that recombinant human IL-6 (rhIL-6) inhibited osteoblast differentiation, as measured by an increase in the immature osteoblast marker, STRO-1 and concomitantly decreased expression of the osteoblast maturation marker, alkaline phosphatase. Importantly, cells cultured in the presence of IL-6 showed significantly less mineral deposition in vitro compared with control cultures. These data suggest that perturbations in bone formation surface, relative to resorption surface, are potentially important in producing bone in the proximal femur with increased propensity to fracture.     

带血运骨瓣移植内固定治疗头下型股骨颈骨折

目的 探讨带自运骨瓣移植治疗股骨颈骨折的疗效。方法 应用带血运骨瓣移植及内固定治疗股骨颈骨折,其中带旋髂深动列脉髂骨瓣10例,带缝匠肌骨瓣6例,带臂中肌骨瓣3例,带阔筋膜张肌骨瓣2例,带股方肌骨瓣3例。结果 24例均获访,时间2．5－6年,疗效评定按童星杰等制定的标准,优15例（62．5％）,良8例（33．3％）,差1例（4．2％）。结论 带血运骨瓣移植是治疗GardenⅢ、Ⅳ型股骨颈骨折方法之一。     

Cost of infection after surgery for intracapsular fracture of the femoral neck

Introduction

We investigated the financial and human costs of postoperative infection for intracapsular fracture of the femoral neck at a district general hospital in the UK.

Methods

Data on postoperative infections after surgical treatment for intracapsular fracture of the femoral neck were collected prospectively from June 2005 to April 2009. Infected patients were pairwise-matched (1:2 ratio) with a non-infected group of patients from a database on hip fractures. Costs of additional surgery, duration of hospital stay, and opportunity costs were calculated using Primary Care Trust (PCT) tariffs and PCT-specific data.

Results

A total of 525 patients were treated with total hip replacement (n=110) or hip hemiarthroplasty (n=415). Seventeen patients (3.2%) were identified as having a surgical-site infection. Eight (1.5%) deep infections and nine (1.7%) superficial infections were documented. Compared with the non-infected group, duration of hospital stay and the prevalence of mortality doubled. Repeat surgery and the costs associated with hospital admission were increased significantly in the infected group. Mean financial loss associated with an infected patient was £7,726, whereas an uninfected patient brought £153 of profit to the hospital. When opportunity costs were considered, an infected patient represented £24,397 of lost income.

Conclusions

Postoperative infection after surgical treatment for intracapsular fracture of the femoral neck has a significant negative impact on duration of hospital stay and financial costs, and demonstrates a trend towards an increase in the prevalence of mortality.     

Osteocytic expression of constitutive NO synthase isoforms in the femoral neck cortex: a case-control study of intracapsular hip fracture.

NO is an osteocytic signaling molecule that can inhibit osteoclasts. The NO synthases eNOS and nNOS were expressed by >50% of osteonal osteocytes in controls. Hip fracture cases showed +NOS osteocytes only in deep osteonal bone, and 25-35% reduced expression overall. These data are consistent with increased osteonal vulnerability to deep osteoclastic attack. INTRODUCTION: Osteocytes may regulate the response to mechanical stimuli in bone through the production of local signaling molecules such as NO derived from the NO synthase eNOS. Because NO is inhibitory to osteoclastic resorption, it has been suggested that osteocytes expressing eNOS act as sentinels, confining resorption within single osteons. Recently, nNOS has been shown to be present in osteocytes of adult human bone. MATERIALS AND METHODS: Cross-sections of the femoral neck (eight female cases of intracapsular hip fracture and seven postmortem controls; age, 68-91 years) were analyzed by immunohistochemistry. The percentages of osteocytes expressing each of these two isoforms were calculated, and their distances to the nearest canal surface were measured. RESULTS: The percentage of +nNOS osteocytes was lower in the fracture cases than in the controls (cases: 43.12 +/- 1.49, controls: 56.68 +/- 1.45; p < 0.0001). Compared with nNOS, eNOS expression was further reduced (p = 0.009) in the cases but was not different in the controls (cases: 36.41 +/- 1.53, controls: 56.47 +/- 2.41; p < 0.0001). The minimum distance of +eNOS or +nNOS osteocytes to a canal surface was higher in the cases compared with controls (eNOS: controls; 44.4 +/- 2.2 microm, cases: 61.7 +/- 2.0 microm; p < 0.0001; nNOS: controls: 52.4 +/- 1.7 microm, cases: 60.2 +/- 2.1 microm; p = 0.0039). +eNOS osteocytes were closer to the canal surfaces than +nNOS osteocytes in the controls by 8.00 +/- 4.0 microm (p = 0.0012). CONCLUSION: The proportions of osteocytes expressing nNOS and eNOS were both reduced in the fracture cases, suggesting that the capacity to generate NO might be reduced. Furthermore, the reduction in NOS expression occurs in those osteocytes closest to the canal surface, suggesting that the ability of NO to minimize resorption depth might be impaired. Further studies are needed on the regulation of the expression and activity of these distinct NOS isoforms.     

Scintigraphical observation to predict fracture healing in intracapsular fracture of the femoral neck

Predictive clinical value of scintigraphical classification of the femoral head in intracapsular fracture of the femoral neck, as classified by Hirano, et al. in 1987, was investigated by long-term follow-up (mean; 4 years and 7 months). Normal healing was achieved in 21 of 24 patients. In those cases, early 99mTc-MDP scintigraphy revealed an over-all increase of radionuclide uptake (Type A) and band-like decrease along the fracture (Type B1). Late segmental collapse of the femoral head was found in 3 patients who showed either a decrease in the weight-bearing area (Type B2) or over-all decrease of radionuclide uptake (Type C). The results of fracture healing were well correlated to each type of scintigraphical classification. The changes of radionuclide uptake in the fracture site were also followed by serial 99mTc-MDP scintigraphy.     

Tetracycline labeling of the femoral head following acute intracapsular fracture of the femoral neck

The purpose of this study was to assess the utility of tetracycline hydrochloride (HCl) labeling of the femoral head following acute intracapsular fracture of the femoral neck to indirectly assess femoral head viability and vascularity. A standard labeling (1.5-3.0 g) and fixative protocol (70% ethanol) was used. The initial tetracycline dose was given in the emergency room. The time from last dose to bone sampling in the operating room ranged from six to 36 hours (average, 21.2 hours). There was no evidence of tetracycline deposition at the bone-osteoid interface in any of the femoral head specimens or the ipsilateral extracapsular greater trochanter control specimens. Sources of labeling failure are multifactorial: problems with label delivery to the patient, in vivo deposition of the label, and the fixation protocol.     

A comparison of hemiarthroplasty with total hip replacement for displaced intracapsular fracture of the femoral neck: a randomised controlled multicentre trial in patients aged 70 years and over

The aim of this study was to analyse the functional outcome after a displaced intracapsular fracture of the femoral neck in active patients aged over 70 years without osteoarthritis or rheumatoid arthritis of the hip, randomised to receive either a hemiarthroplasty or a total hip replacement (THR). We studied 252 patients of whom 47 (19%) were men, with a mean age of 81.1 years (70.2 to 95.6). They were randomly allocated to be treated with either a cemented hemiarthroplasty (137 patients) or cemented THR (115 patients). At one- and five-year follow-up no differences were observed in the modified Harris hip score, revision rate of the prosthesis, local and general complications, or mortality. The intra-operative blood loss was lower in the hemiarthroplasty group (7% > 500 ml), THR group (26% > 500 ml) and the duration of surgery was longer in the THR group (28% > 1.5 hours versus 12% > 1.5 hours). There were no dislocations of any bipolar hemiarthroplasty than in the eight dislocations of a THR during follow-up. Because of a higher intra-operative blood loss (p < 0.001), an increased duration of the operation (p < 0.001) and a higher number of early and late dislocations (p = 0.002), we do not recommend THR as the treatment of choice in patients aged ≥ 70 years with a fracture of the femoral neck in the absence of advanced radiological osteoarthritis or rheumatoid arthritis of the hip.     

Malunion in displaced intracapsular fracture of femoral neck: A rare case

Intracapsular fracture of femoral neck is treated by anatomical reduction (preferably closed) and cannulated cancellous lag screw fixation. Malunion of these fractures have been described in the coronal plane (coxa valga or coxa vara). We reported a case of young adult patient with displaced intracapsular fracture of femoral neck that had malunited in sagittal plane with callus formation with excellent functional outcome. The radiographs revealed intracapsular fracture of femoral neck right side (Garden type 4 and Pauwel type 3). The patient was operated and closed reduction and internal fixation with three cannulated cancellous screws was performed. The postoperative radiograph revealed a loss of reduction in the lateral view. Due to this technical error, the patient was counselled for revision fixation for which he refused. At 9 months we observed union of the fracture in the displaced position by callus formation. Harris hip score at 2 years was 96 that indicate excellent functional outcome and the radiographs did not reveal any evidence of avascular necrosis of femoral head. We advised revision surgery to our patient as he had increased chances of implant failure and nonunion. However he refused the revision surgery and was continued with the suboptimal reduction. However, the fracture united and that too with callus formation, which is not a described phenomenon in neck of femur fracture.     

Magnetic resonance imaging of the femoral head after acute intracapsular fracture of the femoral neck

In fifteen patients who had a subcapital fracture of the femoral neck (twelve displaced fractures and three non-displaced fractures), magnetic resonance imaging of the femoral head was done with two-dimensional Fourier transform spin-echo technique within forty-eight hours of injury. The magnetic resonance image did not show avascular necrosis of the femoral head in any of the patients. In eleven patients, there was a decreased signal at the base of the femoral head, immediately adjacent to the fracture. This decreased signal corresponded to a recognized band of necrosis and hemorrhage next to the site of the fracture and was not related to the viability of the femoral head. No other changes were seen on the images. We concluded that this type of magnetic resonance imaging is inadequate to determine the viability of the femoral head within forty-eight hours after a patient sustains an acute intracapsular fracture of the femoral neck.     

The fate of the articular cartilage in intracapsular fracture of the femoral neck (articular cartilage in femoral neck fracture)

Summary The fate of the articular cartilage of the hip joint with intracapsular neck fracture was studied by histological, histochemical and autoradiographic techniques and by using a polarized microscope and a scanning electron microscope.Cartilage specimens from 93 femoral heads and 7 acetabula were obtained from fractured hips 2 days to 4 1/3 years postfracture and from control hips with various disorders.The cartilage degeneration appeared 2 weeks after fracture and advanced steadily with time. The matrix was covered, invaded and ultimately replaced by the fibrous tissue. Chondrocyte viability, though it was lost from the surface, was recognized in the deep matrix even in the oldest fracture examined.It is concluded that the humoral factor directly caused by the injury as well as the biomechanical impairment, i.e. a loss of physical stress, may play an essential role in the pathogenesis of the degeneration. The possibility of regeneration was discussed.

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Zusammenfassung Um den Verlauf der Knorpeldegeneration im Hüftgelenk mit intrakapsulärer Schenkelhalsfraktur klarzumachen, wurden morphologische und autoradiographische Untersuchungen durchgeführt.2 Wochen nach einer Fraktur fanden sich schon Zeichen von kartilagener Degeneration, und sie entwickelten sich mit der Zeit. Die Matrix war bedeckt, infiltriert, und sie wurde durch fibröse Gebilde ersetzt. Die Chondrocyten überlebten nicht mehr in der Oberfläche, jedoch bleiben sie, sogar an älteren Frakturen, lebhaft in der Tiefe der Matrix.Wir sind der Ansicht, daß nicht nur humorale Faktoren, die direkt durch Unfall ausgelöst wurden, sondern auch biomechanische Läsionen, d. h. Auslösen des physikalischen Streß, eine große Rolle spielen können. Die Möglichkeit der Regeneration wurde diskutiert.

     

Bone remodeling at the endocortical surface of the human femoral neck: a mechanism for regional cortical thinning in cases of hip fracture.

Endocortical remodeling and wall thickness (W.Th.) were measured in femoral neck bone from 12 female fracture cases (81.3 +/- 1.5 years) and 12 sex-matched controls (81.9 +/- 1.9 years). Regionally, osteoid and eroded surface were increased, whereas W.Th. was reduced. These processes likely contribute to cortical bone loss seen in hip fracture. INTRODUCTION: Because periosteal expression of alkaline phosphatase was similar between cases and controls, we hypothesized that the mechanism causing the marked femoral neck cortical thinning associated with hip fracture may be net endocortical bone loss. METHODS: Twelve female cases of femoral neck fracture (mean age = 81.3 +/- 1.5 years) and 12 age- and sex-matched postmortem controls (mean age = 81.9 +/- 1.9 years) were included in the study. Samples of their femoral neck bone were embedded in methyl methacrylate, sectioned at 10 microm, and stained with Solochrome cyanine R and Goldner's trichrome for the detection of osteoid (%OS/BS) and resorption surfaces (%ES/BS) respectively. In addition, wall thickness (W.Th.) and lamellar thickness (Lm.Th.) data were also collected from identifiable endocortical bone packets as a measure of formative potential. RESULTS AND CONCLUSIONS: %OS/BS was significantly elevated in the anterior (control = 3.4 +/- 0.7: fracture = 11.0 +/- 2.3; p = 0.0001), inferior (3.4 +/- 1.0: 9.9 +/- 3.0; p = 0.0009), and posterior quadrants (3.2 +/- 0.8: 9.1 +/- 2.3; p = 0.0021). Only for anterior region was increased %ES/BS demonstrated in the fracture group (2.8 +/- 0.6: 5.3 +/- 0.7; p = 0.055). W.Th. (mm) was reduced only in the inferior region of the fracture cases (control = 33.7 +/- 1.2: fracture = 30.6 +/- 0.9; p = 0.013), whereas Lm.Th. was also reduced inferiorly (control = 2.7 +/- 0.08: fracture = 2.5 +/- 0.08; p = 0.042). These data suggest that an endocortical remodeling imbalance involving reduced bone formation within inferior region coupled with elevated anterior resorption may make an important contribution to the cortical thinning observed in cases of femoral neck fracture.     

Discrimination between cases of hip fracture and controls is improved by hip structural analysis compared to areal bone mineral density. An ex vivo study of the femoral neck

In vivo bone densitometry is affected by measurement inaccuracies arising from the assumptions made about soft tissue and marrow composition. This study tested the hypothesis that section modulus (SM, a measure of bending resistance) when measured ex vivo, would discriminate cases of hip fracture from controls better than areal bone mineral density (aBMD). The biopsies were from (n = 22, female) subjects that had suffered an intracapsular hip fracture. The control material (n = 24, female) was from post-mortem subjects. Serial peripheral quantitative computed tomography (pQCT) 1-mm thick cross-sectional images of femoral neck previously embedded in methacrylate were obtained with the Densiscan 1000 pQCT densitometer and matched for lateral location. The image voxels were converted to units of bone mass, which were then used to derive the section modulus. The data were used to derive means from which receiver operating characteristic (ROC) curves could be generated. The area under the curves (AUC) showed that discrimination between the fracture cases and controls was better for SM than aBMD [SM: AUC = 0.83 (95% confidence interval: 0.71, 0.96), aBMD: AUC = 0.70 (0.54, 0.85); P = 0.034]. To simulate the forces experienced during a sideways fall, the model's neutral axis was rotated by 210 degrees. The results for section modulus were predictable from those at 0 degrees (r(2) = 0.97). We conclude that biomechanical analysis of the distribution of bone within the femoral neck may offer a marked improvement in the ability to discriminate patients with an increased risk of intracapsular fracture. Progress towards implementing this form of analysis in clinical densitometry should improve its diagnostic value, but may depend in part on better image resolution and more accurate corrections for the variability between subjects in regional soft tissue composition.     

Subcapital femoral neck fracture following successful trochanteric fracture treatment with a dynamic hip screw: a report of five cases

A subcapital femoral neck fracture complicating a healed trochanteric fracture is rare. Such cases are managed in a rather heterogeneous manner, i.e. there exists a mixture of cases treated by either fixed angle devices or dynamic compression screws. We describe 5 patients who developed subcapital femoral neck fractures after healed trochanteric fractures treated with dynamic compression screws. The subjects' clinical data, operative records, and radiographs have been studied retrospectively and the literature reviewed. The risk factors for such a complication include being of advanced age, female, osteoporotic, and having a small femoral head and neck, and a basicervical type of fracture.     

The effect of shortening and varus collapse of the femoral neck on function after fixation of intracapsular fracture of the hip: a multi-centre cohort study

We have studied the effect of shortening of the femoral neck and varus collapse on the functional capacity and quality of life of patients who had undergone fixation of an isolated intracapsular fracture of the hip with cancellous screws. After screening 660 patients at four university medical centres, 70 patients with a mean age of 71 years (20 to 90) met the inclusion criteria. Overall, 66% (46 of 70) of the fractures healed with > 5 mm of shortening and 39% (27 of 70) with > 5 degrees of varus. Patients with severe shortening of the femoral neck had significantly lower short form-36 questionnaire (SF-36) physical functioning scores (no/mild (<5 mm) vs severe shortening (> 10 mm); 74 vs 42 points, p < 0.001). A similar effect was noted with moderate shortening, suggesting a gradient effect (no/mild (< 5 mm) vs moderate shortening (5 to 10 mm); 74 vs 53 points, p = 0.011). Varus collapse correlated moderately with the occurrence of shortening (r = 0.66, p < 0.001). Shortening also resulted in a significantly lower EuroQol questionnaire (EQ5D) index scores (p = 0.05). In a regression analysis shortening of the femoral neck was the only significant variable predictive of a low SF-36 physical functioning score (p < 0.001).