Revision Surgery Occurs Frequently After Percutaneous Fixation of Stable Femoral Neck Fractures in Elderly Patients

Background

Femoral neck fractures are a major public health problem. Multiple-screw fixation is the most commonly used surgical technique for the treatment of stable femoral neck fractures.

Questions/purposes

We determined (1) the proportion of hips that had conversion surgery to THA, and (2) the proportion of hips that underwent repeat fracture surgery after percutaneous screw fixation of stable (Garden Stages I and II) femoral neck fractures in patients older than 65 years and the causes of these reoperations.

Methods

We performed a retrospective study of all patients older than 65 years with stable femoral neck fractures secondary to low-energy trauma treated surgically at our institution between 2005 and 2008. We identified 121 fractures in 120 patients older than 65 years as stable (Garden Stage I or II); all were treated with percutaneous, cannulated screw fixation in an inverted triangle without performing a capsulotomy or aspiration of the fracture hematoma at the time of surgery. The average age of the patients at the time of fracture was 80 years (range, 65–100 years). Radiographs, operative reports, and medical records were reviewed. Fracture union, nonunion, osteonecrosis, intraarticular hardware, loss of fixation, and conversion to arthroplasty were noted. Followup averaged 11 months (range, 0–5 years) because all patients were included, including those who died. The mortality rate was 40% for all patients at the time of review.

Results

Twelve patients (10%) underwent conversion surgery to THA at a mean of 9 months after the index fracture repair (range, 2–24 months); the indications for conversion to THA included osteonecrosis, nonunion, and loss of fixation. Two others had periimplant subtrochanteric femur fractures treated by surgical repair with cephalomedullary nails and two patients had removal of hardware.

Conclusions

Revision surgery after osteosynthesis for stable femoral neck fractures was more frequent in this series than previously has been reported. The reasons for this higher frequency of reoperation may be related to poor bone quality, patient age, and some technical factors, which leads us to believe other treatment options such as nonoperative management or hemiarthroplasty may be viable options for some of these patients.

Level of Evidence

Level IV, therapeutic study.     

The clinical outcomes of early internal fixation for undisplaced femoral neck fractures and early full weight-bearing in elderly patients

Objective

The purpose of the present study was to evaluate the clinical outcomes of early internal fixation for undisplaced femoral neck fractures and early full weight-bearing in patients aged 65 years and older.

Patients and methods

The records of consecutive patients who underwent surgery for undisplaced femoral neck fractures between 1999 and 2011 were retrospectively reviewed. The patients underwent the surgery as early as possible, and allowed early full weight-bearing. The interval between initial injury and surgery, time to admission and operation, operation time, decrease in hemoglobin, the postoperative day starting to walk, postoperative walking status, and the incidence of any secondary procedures were evaluated. The average patient age was 77.5 years and the average duration of postoperative follow-up was 46.8 months. The patients were divided to two groups to determine the effect of early operation: the early operation group within 24 h on admission, and the late operation group done 24 h after admission.

Results

Eighty-six percent of surgeries were performed within 48 h of admission. The average operation time was 46 min (range 20–95 min). Transfusions were performed in 6.9 % (4/58) of patients. The mortality rate was 6.9 %, and the rate of complications was 9.3 % (5/54): four cases of avascular necrosis (AVN) and one case of fixation failure. The rate of secondary procedures was 7.4 % (4/54). Seventy-two percent (39/54) of patients recovered their postoperative walking ability to pre-injury levels.

Conclusion

This study demonstrated that early internal fixation of undisplaced femoral neck fractures in elderly patients produced satisfactory clinical outcomes.     

Clinical results of treatment of garden type 1 and 2 femoral neck fractures in patients over 70-year old

Introduction

We retrospectively analyzed the clinical results of treatment of impacted or undisplaced femoral neck fractures (Garden types 1 and 2) by osteosynthesis in elderly patients >70-year old.

Materials and methods

We retrospectively reviewed the radiological results of 52 patients who were followed up for at least 6 months from April 2002 to December 2008. The average age of the patients was 77.6 years (range 70–97 years), and 38 patients were females. The mean follow-up period was 11.7 months (range 6–19 months). Thirteen cases were Garden type 1 fractures, and 39 were Garden type 2 fractures. We assessed the relationships between the occurrence of complications and age, sex, Garden stage, bone mineral density (BMD), history of contralateral hip fracture, and any additional hip injury.

Results

Major complications occurred in 18 cases (34.6 %), including nonunion (8 cases), osteonecrosis (6 cases), stress fracture of the subtrochanter (2 cases), excessive pull-out of a screw (1 case), and deep infection (1 case). The development of complications was associated with Garden stage 2, BMD, and additional hip injury. However, other factors were not associated with complications. Reoperations were performed in 16 cases (30.1 %), and 2 of the patients died during follow-up.

Conclusion

A relatively high rate of complications or reoperations developed after treatment of Garden 2 femoral neck fractures in senile patients >70 years of age with osteoporosis. Although internal fixation has been recommended in the literature for undisplaced femoral neck fractures, primary arthroplasty may be a better option for treatment of Garden type 2 fractures in elderly patients.

     

Factors associated with avascular necrosis of the femoral head and nonunion in patients younger than 65 years with displaced femoral neck fractures treated with reduction and internal fixation

Introduction

Few studies have evaluated treatment of displaced femoral neck fractures in patients younger than 65 years, and risk factors for AVN or nonunion have not been clearly delineated within this age range.

Method

To determine factors associated with avascular necrosis of the femoral head (AVN) and nonunion in patients younger than 65 years with displaced femoral neck fractures treated with reduction and internal fixation, we conducted a retrospective study of 29 displaced femoral neck fractures in 29 consecutive patients treated at a single institution. The influence of age, trauma energy, open reduction, and time from fracture to treatment on development of AVN and nonunion was evaluated.

Results

Patients who developed AVN were significantly older and suffered lower energy trauma than cases without AVN. No recorded variables were associated with nonunion. Logistic regression determined that only age was independently associated with AVN. Age was a good predictor for developing AVN, with a C statistics of 0.861, and a best cutoff determined at 53.5 years.

Conclusion

Patients between 53.5 and 65 years presented a higher risk of AVN. A primary arthroplasty should be considered in this subgroup.     

Targon® Femoral Neck for femoral-neck fracture fixation: lessons learnt from a series of one hundred and thirty five consecutive cases

Purpose

Internal fixation versus joint replacement for treating intracapsular hip fractures is still a major debate. The Targon® FN fixation concept is innovative; two small case series are promising. We present the first larger series.

Methods

We conducted prospective documentation of all Targon® FN cases since 2006. The implant was used for all undisplaced fractures, and for displaced fractures in patients of a biological age ≤60 years. Besides demographic data and fracture classification, we analysed infection, haematoma, implant perforation, nonunion and operative revision procedures.

Results

In 135 cases (mean age 71 years; average operation time 60 minutes; average hospital stay ten days), we found a surgical complication rate of 16.4 %. Conversion to joint replacement was necessary in 9.6 %. Complication rate was significantly higher in displaced fractures.

Conclusions

Our study confirms low general complication rates. However, implant perforation seems to be underestimated. Optimised reduction technique may help to reduce this complication.     

The effect of renal function on surgical outcomes of intracapsular hip fractures with osteosynthesis

Background

Chronic kidney disease (CKD) affects many physiologic systems, including bone quality, nutrition, and cardiovascular condition. Femoral neck fractures in patients on dialysis are associated with frequent complications and a high risk of mortality. However, the effect of CKD on clinical outcomes of patients with hip fractures treated with osteosynthesis remains unclear.

Methods

One hundred and thirty patients with 130 femoral neck fractures treated with internal fixation were divided into two groups and the data were then analyzed. Group 1 consisted of 98 patients (98 hip fractures) with normal renal function (estimated glomerular filtration rate, or eGFR, ≥60 ml/min/1.73 m²). Group 2 was composed of 32 patients (32 hip fractures) with CKD (eGFR <60 ml/min/1.73 m²) without dialysis. Clinical outcomes as well as early and late complications were recorded for each group. Survivorship analysis was performed, and the mortality and complication rates for the groups were then compared.

Results

In Group 1, 32 complications (32.6 %) occurred in 98 hips, including 5 cases of nonunion and 16 cases of osteonecrosis. In Group 2, 24 complications (75 %) developed in 32 hips; these included 8 cases of nonunion and 3 cases of osteonecrosis. The mean duration of follow-up was 32 months. The overall mortality rate was 11.5 %. No difference was noted in early, late, or overall mortality rate between two groups. Patient with CKD had a higher nonunion rate (OR = 5.9, P = 0.023). Meanwhile, CKD and displaced fracture pattern were independent predictors for revision surgery (OR = 3.0, P = 0.032; OR = 6.9, P = 0.001, respectively).

Conclusions

Osteosynthesis is a safe and effective treatment for femoral neck fractures; however, patients with femoral neck fracture and CKD have a higher risk of nonunion and subsequent surgical revision.

Level of relevance

Prognostic studies, Level III.     

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.     

Lateral cortical notching in specific cases of delayed unions or nonunions after intertrochanteric and reversed fractures

Background

Stabilization of both intertrochanteric and reversed trochanteric fractures is commonly performed by proximal femoral nailing. However, biomechanics significantly differ between these two fracture types.

Patients and methods

In this study we report on the occurrence of delayed union or nonunion after inter- or reversed trochanteric fractures in eight patients (7 females and 1 male).

Results

Mean age was 73.3 years (range 63–82). The interval between initial operation and first intervention ranged between 4.3 and 15.0 months (mean 8.4 months). Failure of bone healing may cause permanent strain on the implant leading to nail breakage, which we observed in three of these eight cases.

Conclusion

Dynamization is part of the general treatment concept for delayed union and nonunion after intramedullary fracture fixation. Normally it is performed by removal of interlocking screws or by occupying a ‘dynamic’ interlocking hole. We can show, however, that some types of inter- and reversed trochanteric fractures develop a characteristic kind of nonunion at the level of the lesser trochanter. This condition causes pain while walking and includes the risk of implant failure due to material fatigue. In these cases dynamization may be blocked by the cortex of the distal fragment directly contacting the prominent lag screw or its sleeve. We describe a procedure we call “lateral notching”, which is needed to make distal conventional dynamization effective and to allow for bone healing.     

Low failure rate by means of DLBP fixation of undisplaced femoral neck fractures

Background

This study evaluated the clinical results of a new implant in the internal fixation of undisplaced femoral neck fractures.

Method

Irrespective of their age, 149 patients with undisplaced (Garden I and II) femoral neck fractures were included in a prospective multicentre clinical cohort study and were treated by internal fixation by means of the Dynamic Locking Blade Plate (DLBP). The mean age was 69 years and the follow-up at least one year.

Results

The DLBP fixation resulted in 6 out of 149 failures caused by AVN (2x), non-union (2x), loss of fixation (3x) or combination of these.

Conclusion

The fixation of undisplaced femoral neck fractures by the DLBP resulted in a low failure rate of 4 %.

     

Infra-isthmal fracture is a risk factor for nonunion after femoral nailing: a case–control study

Background

The rates of nonunion after femoral nailing are currently reported to be 4.1–12.5 %. The purpose of this study was to identify the risk factors of noninfected nonunion after femoral nailing, focusing in particular on the effects of the length of the distal main fragment.

Methods

A case–control study was conducted with 105 patients, with a case (nonunion group)–control (control group) ratio of 1:2. The nonunion group (n = 35) comprised patients with consecutive symptomatic nonunions after femoral nailing who were treated in our institute; the control group (n = 70) were matched by age to the nonunion group. Type of fracture, soft tissue injury, length of femur and nail length, incidence of screw breakage, nail diameter, mean length of distal main fragment, and any episode of dynamization were retrospectively examined. Univariate and multivariate analyses were performed to elucidate the risk factors of nonunion after femoral nailing.

Results

Increased risk of nonunion after femoral nailing was associated with (1) open fracture, (2) screw breakage, (3) shorter length of a distal fragment, and (4) any episodes of dynamization. Receiver operating characteristic analysis showed that a distal fragment length of <43 % of the total femur length was the cutoff level for nonunion after nailing. The odds ratio for nonunion was 6.40 (95 % CI 2.70–15.2) when the length of the distal main fragment was <43 % of the femur length. Multivariate logistic analysis revealed that the risk of nonunion after femoral nailing increased (1) with breakage of locking screws (p = 0.0021), (2) with dynamization (p = 0.0029), (3) with a shorter distal fragment length (p = 0.0379), and (4) with an open fracture (p = 0.0397).

Conclusion

The elucidated risk factors of nonunion after femoral nailing were identified as open fracture, infra-isthmal femoral fracture, breakage of locking screw, and inappropriate dynamization. We believe that the surgeon should be consciously aware of the need for additional surgical fixation for the distal fragment when performing femoral nailing of infra-isthmal femoral fractures.     

Revision rates and cumulative financial burden in patients treated with hemiarthroplasty compared to cannulated screws after femoral neck fractures

Introduction

This study compares re-operation rates and financial burden following the treatment of femoral neck fractures treated with hemiarthroplasty compared to non-displaced femoral neck fractures treated with cannulated screws.

Methods

Data was retrospectively analyzed from a prospective database at a university hospital setting on patients undergoing hemiarthroplasty after femoral neck fractures and those with non-displaced femoral neck fractures treated with cannulated screws over a 7-year period. Re-operation rates were determined and financial data was analyzed. Charges refer to amounts billed by the hospital to insurance carriers, while costs refer to financial burden carried by the hospital during treatment.

Results

There were 491 femoral neck fractures (475 patients) that underwent hemiarthroplasty (HA) and 120 non-displaced fractures (119 patients) treated with cannulated screw (CannS) fixation. Both groups had similar age, sex, Charlson co-morbidity scores, pre-operative Parker mobility scores, and 12-month mortality. There were 29 (5.9 %) reoperations in the HA group and 16 (13.3 %) in the CannS group (P = 0.007). The majority of re-operations occurred within 12 months for both groups [21/29 (72 %) HA group; 15/16 (94 %) CannS group; P = 0.13]. Average hospital charges per patient for the index procedure were higher in the HA group ($17,880 ± 745) compared to the CannS group ($14,104 ± 5,047; P < 0.001). After accounting for additional procedures related to their initial surgical fixation, average hospital charges and costs remained higher in the HA group.

Conclusion

Patients treated with hemiarthroplasty for femoral neck fractures have lower re-operation rates than patients treated with cannulated screws for non-displaced femoral neck fractures, with 80 % of re-operations occurring in the first 12 months. Hospital charges and costs to the hospital for treating patients undergoing hemiarthroplasty were higher than patients treated with cannulated screws for the index procedure alone, and after accounting for re-operations.     

The use of the 95-degree-angled blade plate in femoral nonunion surgery

Introduction

The 95-degree-fixed angle blade plate has been in use for decades for both acute femoral fractures and nonunions. Our objective was to examine the results of use by a single surgeon of the 95-degree-angled blade plate in proximal and distal femoral nonunion surgery.

Patients and methods

The nonunion database of a single surgeon over a 16 year period was used to identify all proximal and distal femoral nonunions that were treated with open reduction and internal fixation using the 95-degree-angled blade plate. There were 78 cases in which the blade plate was used, and 68 of 78 (87.2 % follow-up rate) were followed to a final outcome, which was defined as complete healing of the nonunion, conversion to arthroplasty, or amputation. Failure was defined as revision surgery for persistence of nonunion, conversion to arthroplasty prior to healing, or amputation. Three patients who failed were lost to follow-up prior to a final outcome.

Results

In the 71 patients who were followed to failure or complete follow-up, the rate of healing with one surgery was 77.5 % (55 of 71). Eight of 16 failures required a second surgery for persistence of nonunion and eventually went on to heal the nonunion. Eleven of the 16 failures were in patients who had a known infected nonunion. When the 21 cases of infected nonunions were excluded, the healing rate for aseptic nonunions with one surgery alone using the 95-degree-angled blade plate was 91.2 % (52 of 57) compared with 47.6?% (10 of 21) in the infected nonunion group (p?<?0.0001). Eleven patients who had healed their nonunion underwent all or partial removal of the implant for irritation or prominence.

Conclusion

The 95-degree-angled blade plate is an effective reduction aid and fixation device for aseptic nonunions of the proximal and distal femur with acceptable healing rates with one surgery alone.     

Management von Kombinationsfrakturen des Femurschafts und des proximalen Femurs

Purpose

The combination of ipsilateral femoral neck and shaft fractures remains a treatment challenge in orthopedic surgery because both fracture types constitute separate entities and require specific treatment concepts.

Material and methods

In a case control study, incidence, treatment strategies, and outcomes of this injury were analyzed. All patients with femoral fractures treated between 1 January 2001 and 31 July 2007 at a level I trauma center were included in the study.

Results

Twenty-one out of 1,935 patients (1.1%) sustained 22 combined fractures of the femoral neck and shaft. Also considering the combination of femoral shaft fractures with fractures of the acetabulum and the distal femur (knee), the proportion of chain injuries of the femur was 3.1%. The rate of multiply injured patients in the group of patients with ipsilateral femoral neck and shaft fractures was 64%. The majority of the patients could be treated with a single implant for both fracture components. The leading fracture component was the femoral neck fracture in eight cases. All fractures consolidated after 4.7 months on average; one pseudarthrosis of the femoral neck was observed. All fractures were discovered in the course of primary diagnostic measures; in 73% of the patients, a computed tomography (CT) body scan was done. Fifty-nine percent of the patients with ipsilateral femoral neck and shaft fractures received primary definitive operative care. Complications included two torsional failures that needed correction and one case of postoperative infection that was easily treated.

Conclusion

Treatment of ipsilateral femoral neck and shaft fractures is still demanding, but diagnosis has improved with regular use of CT body scans in the management of multiply injured patients. Furthermore, possibilities for operative treatment have been advanced by the introduction of the long proximal femoral nail and the antegrade femoral nail, two implants supporting stabilization of these fracture entities.     

Cumulative incidence and treatment of non-simultaneous bilateral femoral neck fractures in a cohort of one thousand two hundred and fifty patients

Purpose

In the Netherlands, over 20,000 patients sustain a hip fracture yearly. A first hip fracture is a risk factor for a second, contralateral fracture. Data on the similarity of the treatment of bilateral femoral neck fractures is only scarcely available. The objectives of this study were to determine the cumulative incidence of non-simultaneous bilateral femoral neck fractures and to describe the patient characteristics and treatment characteristics of these patients.

Methods

A database of 1,250 consecutive patients with a femoral neck fracture was available. Patients with a previous contralateral femoral neck fractures were identified by reviewing radiographs and patient files. Patient characteristics, previous fractures, hip fracture type and details on treatment were collected from the patient files.

Results

One hundred nine patients (9 %, 95 % confidence interval 7–10 %) had sustained a non-simultaneous bilateral femoral neck fracture. The median age at the first fracture was 81 years; the median interval between the fractures was 25 months. Overall, 73 % was treated similarly for both fractures in terms of non-operative treatment, internal fixation or arthroplasty. In patients with identical Garden classification (30 %), treatment similarity was 88 %.

Conclusions

The cumulative incidence of non-simultaneous bilateral femoral neck fractures was 9 %. Most patients with identical fracture types were treated similarly. The relatively high risk of sustaining a second femoral neck fracture supports the importance of secondary prevention, especially in patients with a prior wrist or vertebral fracture.     

Undisplaced intracapsular hip fractures in the elderly: predicting fixation failure and mortality. A prospective study of 162 patients

Background

Reported revision of internal fixation for undisplaced intracapsular hip fractures is between 12 and 17 % at 1 year. This risk is greater for elderly patients, for whom mortality after such a fracture is also higher. Our purpose was to identify predictors of fixation failure and mortality for elderly patients sustaining undisplaced intracapsular hip fractures, and to assess whether their socioeconomic status affected their outcome.

Methods

During a 3-year period we prospectively compiled a consecutive series of 162 elderly (≥65 years old) patients who underwent internal fixation for an undisplaced (Garden stage I or II) intracapsular hip fracture. Patient demographics, American Society of Anesthesiologists (ASA) grade, and posterior tilt (measured on the lateral radiograph) were recorded pre-operatively. All patients were followed up for a minimum of 1 year. Each patient’s socioeconomic status was assigned by use of the Scottish Index of Multiple Deprivation. Patient mortality was established by use of the General Register Office for Scotland.

Results

There were 28 failures of fixation during the study period. In Cox regression analysis, ASA grade and the presence of posterior tilt (p < 0.0001) were significant independent predictors of fixation failure. Overall unadjusted mortality at 1 year was 19 % (n = 30/162). Cox regression analysis also affirmed ASA grade to be the only significant independent predictor of 1-year mortality (p = 0.003). The standardised mortality rate for the cohort was 2.3 (p < 0.001), and was significantly greater for patients less than 80 years of age (p = 0.004). Socioeconomic status did not affect outcome, but the most deprived patients sustain their fracture at a significantly younger age (p = 0.001).

Conclusion

We have demonstrated that ASA grade and posterior tilt of the femoral neck are independent predictors of fixation failure of undisplaced intracapsular hip fractures in elderly patients, and ASA grade was also an independent predictor of mortality.     

Surgical procedures in femoral neck fractures in Finland: a nationwide study between 1998 and 2011

Purpose

For femoral neck fractures, recent scientific evidence supports cemented hemiarthroplasty (HA) over uncemented HA and suggests that total hip arthroplasty (THA) should be performed more frequently. We report the current surgical trends in treating femoral neck fractures in Finland.

Methods

The study was conducted using the Finnish National Hospital Discharge Register and included all Finns at least 50 years of age who underwent surgery for femoral neck fractures from 1998 through 2011. Age- and sex-specific incidence rates and annual proportion of each treatment method were calculated.

Results

During 1998–2011, a total of 49,514 operations for femoral neck fracture were performed in Finland. The proportion of uncemented HA increased from 8.1 % in 2005 to 22.2 % in 2011. During the same time, the proportion of cemented HA decreased from 63.9 to 52.5 %, internal fixation decreased from 23.2 to 16.1 % and THA increased from 4.9 to 9.2 %.

Conclusions

Between 2005 and 2011, the proportion of uncemented HA for femoral neck fractures increased markedly in Finland, while cemented HA and internal fixation declined. During this time, the use of THA nearly doubled. The current evidence-based guidelines for treatment of femoral neck fractures were mainly followed, but the increase in uncemented HA procedures contradicts recent scientific evidence.     

Einfluss des Operationszeitpunkts und -verfahrens auf Mortalität und Frühkomplikationen der Schenkelhalsfraktur

Background

The current S2 guideline recommends treatment of a femoral neck fracture within the first 24 h; this becomes evident by the significant rise in general and early surgical complications, when the surgical treatment was delayed for more than 48 h. The influence of different surgical procedures was investigated.

Patients und methods

A total of 22,566 records from the external Quality Assurance Program in North Rhine-Westphalia for treatment of femoral neck fractures in 2004/2005 (BQS specification 7.0 and 8.0) were risk-adjusted and evaluated.

Results

Surgery was performed within 48 h in 83.9% of the patients. A significant rise in general and early surgical complications was registered when the surgical treatment was delayed for more than 48 h. Mortality and general complications were significantly lower for percutaneous screw fixation. All kinds of joint replacement show significantly higher general and surgical complications.

Conclusion

The analyzed data support the rating of femoral neck fracture as requiring the intervention of urgent early surgery, as stated in the guideline. Percutaneous screw fixation can be considered for immobile and multimorbid patients with undislocated fractures. Advantages of total hip replacement compared to hemiarthroplasty cannot be supported by the QS-NRW data.     

Risk of acetabular protrusion is low in rheumatoid arthritis patients treated with bipolar hemiarthroplasty for displaced femoral neck fractures without rheumatoid change in hip joints

Objectives

The aim of this study was to analyze the radiological outcomes of bipolar hemiarthroplasty after displaced femoral neck fractures of non-arthritic hip joints in rheumatoid arthritis patients.

Methods

We retrospectively investigated 25 hip joints in 23 rheumatoid arthritis patients who underwent bipolar hemiarthroplasty for displaced femoral neck fracture of non-arthritic hip joints. All patients were female with an average age of 69.8 years (range 51–83 years). Mean follow-up duration was 8.4 years (range 5–12 years). Radiographs taken immediately, 1 year after surgery and most recently, were collected for each case. Radiographic measurement of the migration distance of the outer-head prosthesis in the direction of vertical, horizontal and medial to Köhler’s line was undertaken at 1 year after surgery and most recently.

Results

No patients had hip-related pain after surgery. No case indicated apparent central migration and >3-mm migration of the hemisphere in each direction. There was no significant change in migration distance between evaluation at 1 year after surgery and most recently.

Conclusions

We conclude that risk of acetabular protrusion appears to be low in patients of rheumatoid arthritis treated with bipolar hemiarthroplasty for displaced femoral neck fractures of non-arthritic hip joints in the medium term.     

Primary total hip arthroplasty versus internal fixation in displaced fracture of femoral neck in sexa- and septuagenarians

Background

The optimal treatment of femoral neck fracture in the elderly patient is still under debate. In patients aged 60–80 years, the decision between internal fixation and arthroplasty remains controversial. The primary aim of the present study is to evaluate the functional outcome of patients aged 60–80 years with femoral neck fracture treated with total hip arthroplasty or closed reduction and internal fixation. The secondary aim is to evaluate the incidence of nonunion and avascular necrosis in femoral neck fracture in different age groups.

Materials and Methods

We studied 100 patients affected by displaced fracture of the femoral neck from May 2007 through June 2010. There were 60 men and 40 women with mean age of 66 years. Fifty patients were treated with closed reduction and internal fixation with cannulated screws (group A), and the other 50 patients with total hip arthroplasty (group B). Mean surgical time, blood loss, duration of hospital stay, Harris hip score, complications, and need for reoperation were recorded.

Results

Harris hip score was significantly higher in group B at 3-, 6-, 12-, and 18-month follow-up evaluation. The overall complication rate was 28 % in group A and 32 % in group B, which was not statistically significant. A statistically significant difference was found regarding patients who required reoperation in group A (20 %) compared with group B (no one). The average Harris hip score in the internal fixation group was 90.6 and in the total hip arthroplasty group was 93.7, which was statistically significant (p < 0.05). Our study showed an increased risk for intracapsular hip fracture developing nonunion with older age.

Conclusions

Primary total hip arthroplasty compared with internal fixation appears to be a reasonably safe method of treating displaced fracture of femoral neck in elderly patients. We also concluded that outcome regarding hip function is generally better after total hip arthroplasty compared with internal fixation.

Level of evidence

Level II-Prospective cohort study.