The treatment of femoral neck fractures: results using cephalocervical screws with sliding mechanism

Background

A new device for the treatment of femoral neck fractures that uses 2 cephalocervical screws in a sliding mechanism allowing linear intraoperative and postoperative compression has been developed. The purpose of this retrospective study was to determine the results using this device for the treatment of stable and unstable femoral neck fractures.

Methods

Between November 2007 and November 2011, 61 consecutive skeletally mature patients with femoral neck fractures were treated with a new cephalocervical screw (Dual SC screw; KISCO DIR Co., Ltd., Kobe). All contactable patients were followed up for a minimum of 16 weeks postoperatively (range 16–123 weeks). Clinical and radiographic examinations were performed at the final evaluation. Healing and return to activities of daily living were used to evaluate outcomes.

Results

There were 51 women and 10 men with a mean age of 80.8 years (range, 41–99). The average of surgical time was 33.1 min (21–66 min). One patient died, one was too infirm for follow-up, and eleven could not be located, leaving 48 patients available for final evaluation (78.7 %). The overall incidence of nonunion was 10.4 %. Fracture nonunion was less common for undisplaced fractures than for displaced fractures (1 of 21 [4.8 %] vs. 4 of 27 [14.8 %]). The mean amount of collapse of the neck was 5.45 mm (3.92 mm in undisplaced and 6.64 mm in displaced). Radiographic analysis at final evaluation revealed no implant failures. 62.5 % of the patients recovered their prefracture status.

Conclusion

The Dual SC screw device appears to be a reliable implant for the treatment of femoral neck fractures. Its design contributes to overcome the implant failures such as a medial migration, cut-out, or back-out; besides, the union rate of this implant was considered superior to that of existing systems. If the early shortening of the neck occurs after this surgery, the surgeons should be considered to keep them partially weight bearing or choose a replacement procedure for such patients.     

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 %.

     

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.     

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.     

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.     

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.     

Role of muscle pedicle bone graft as an adjunct to open reduction and internal fixation in the management of neglected and ununited femoral neck fracture in young adults: a prospective study of 17 cases

Aim

To evaluate the role of quadratus femoris muscle pedicle bone grafting along with open reduction and internal fixation in the treatment of neglected and ununited femoral neck fractures in young adults.

Materials and methods

Young adults within the age group of 15–45 years with ununited, old neglected fractures of femoral neck were included in the study. All patients underwent quadratus femoris muscle pedicle bone grafting along with open reduction and internal fixation. The post-operative complications and functional recovery was assessed using Charnley’s modification of Merle D’Aubigne and Postel hip scoring.

Results

A total of 17 patients were included in the study. The average time of union following the procedure was found to be approximately 8 months. There were two cases of delayed union and no cases of avascular necrosis. Ten patients (58.8 %) had excellent or very good post-operative functional results and 6 patients (35.3 %) had good or satisfactory results.

Conclusion

Muscle pedicle bone grafting is a useful adjunct to open reduction and internal fixation for ununited femoral neck fractures. It achieves good final functional results comparable with other methods, but requires greater expertise.     

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.     

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.

     

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.     

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.     

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.     

Minimally invasive periprosthetic plate osteosynthesis using the locking attachment plate

Objective

Stable fixation of periprosthetic or periimplant fractures with an angular stable plate and early weight bearing as tolerated.

Indications

Periprosthetic femur fractures around the hip, Vancouver type B1 or C. Periprosthetic femur and tibia fractures around the knee. Periprosthetic fractures of the humerus. Periimplant fractures after intramedullary nailing.

Contraindications

Loosening of prosthesis. Local infection. Osteitis.

Surgical technique

Preoperative planning is recommended. After minimally invasive fracture reduction and preliminary fixation, submuscular insertion of a large fragment femoral titanium plate or a distal femur plate. The plate is fixed with locking head screws and/or regular cortical screws where possible. If stability is insufficient, one or two locking attachment plates (LAP) are mounted to the femoral plate around the stem of the prosthesis. After fixing the LAP to one of the locking holes of the femoral plate, 3.5 mm screws are used to connect the LAP to the cortical bone and/or cement mantle of the prosthesis.

Postoperative management

Weight bearing as tolerated starting on postoperative day 1 is suggested under supervision of a physiotherapist.

Results

In 6 patients with periprosthetic fractures and 2 patients with periimplant fractures, no surgical complications (e.g., wound infection or bleeding) were observed. The mean time to bony union was 14 weeks. No implant loosening of the locking attachment plate was observed. At the follow-up examination, all patients had reached their prefracture mobility level.     

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.     

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.     

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.     

Management pitfalls of fractured neck of femur in osteogenesis imperfecta

Introduction

Fractured neck of femur in osteogenesis imperfecta is rarely reported. Its management is always difficult because of bone fragility and the outcome is not well known. We, therefore, aimed to study the management pitfalls in this group of patients.

Methods

We retrospectively reviewed five cases of fractured neck of femur in four patients treated in our hospital between 2006 and 2009. The demographic data, mode of injury, fracture configuration, treatment, complications, clinical and radiological outcome were reviewed.

Results

According to the Sillence classification, one patient was type I, two were type III and one was type IV. There were two children (aged 8 and 15 years) and two adults (aged 21 and 22 years), with the 8 year-old girl suffering from hip fracture on different sides in two accidents. All five hip fractures were the result of low-energy injury and were associated with other fractures. Two undisplaced fractures required intra-operative fluoroscopic confirmation to demonstrate movement at the fracture site. The interval between the injury and fixation ranged from 6 h to 3 days. One hip required secondary surgery to openly reduce the fracture due to inadequate primary fixation and reduction. Two hips were fixed with paediatric dynamic hip screws and three hips were fixed with cannulated screws. All patients were immobilised in hip spica for 6 weeks. The average follow-up was 4 years (3–5 years). All patients had satisfactory union and none of them developed radiological evidence of avascular necrosis at the latest follow-up. All patients returned to their pre-injury functional level.

Conclusion

Fractured neck of femur is rare given the high prevalence of long bone fractures in osteogenesis imperfecta. They all have characteristic associated fractures of the extremity at the time of injury and neck of femur fractures could be easily missed. Fracture fixation is a great challenge to the orthopaedic surgeons because of the small size of the patients, poor bone quality with suboptimal imaging intra-operatively and compromised purchase of fixation devices. The choice of implants should be determined by the size of the patients and the presence of prior instrumentation close to the hip joint.     

Mediale Schenkelhalsfraktur: mögliche Gründe für eine verzögerte operative Versorgung

Problem

In Germany a disproportionate number of patients with a femoral neck fracture still experience a delay in surgery. In 2008 delays of more than 48 h after admission occurred for 15.4 % of patients. This leads to increases in surgical and general complications as well as pressure sores.

Objective

Possible reasons that lead to delayed operations were investigated in a nationwide study.

Data and methods

Using nationwide data from the German inpatient external quality assurance program from the year 2008 the reasons for performing operations later than 48 h after hospital admission were examined both exploratory and analytically using a multiple logistic regression model considering combined effects.

Results

Surgery was more frequently delayed for patients who were admitted to hospital on Friday or Saturday, patients with a higher American Society of Anesthesiologists (ASA) classification, men, patients with malignant diseases, in the presence of infectious diseases and patients with heart disease. Operations carried out within the first 48 h were more frequent with displaced fractures and in the presence of hypertension or mental illness. The volume per hospital had no consistent effect on the time delay of surgery. During the week no significant differences between the departments were detected. On Friday or Saturday surgery was delayed more often when patients were admitted to a department of general surgery than to a department of trauma surgery or orthopedics.

Conclusions

There are medical and non-medical reasons for delayed surgery of femoral neck fractures. Studies have confirmed that delayed surgery for femoral neck fracture harms the patients. Organizational reasons which prevent an immediate operation, e.g. admission on Friday or Saturday, should therefore be eliminated by improvements in hospital organization and staffing. These can be measures of individual hospitals or of several hospitals in cooperation. The target should be to ensure a comprehensive and timely provision of the highest quality care even at the weekend.     

Stabilisierung sub- und pertrochant?rer Femurfrakturen mit dem PFN��?

Objective

Intramedullary nail system fixation of inter- and subtrochanteric femoral fractures allows early weight-bearing, especially in osteoporotic bone. Restoration of anatomical shape and early return to function of the injured leg.

Indications

All inter- and subtrochanteric fractures of AO type 31-A without limitation.

Contraindications

Open physes and unsuitable femoral shaft anatomy (increased anterior bow of femoral shaft or malunion after femoral fracture).

Surgical technique

If possible closed, otherwise open fracture reduction on a fracture table and unreamed intramedullary nailing. Fixation of the fracture by insertion of a helical blade via a guide wire in the head?Cneck fragment of the femur. Option of static or dynamic locking at the femoral diaphysis.

Postoperative management

Early mobilization immediately the day after surgery with full weight-bearing and use of assistive device, as tolerated. Thrombosis prophylaxis for 6 weeks with fondaparinux, rivaroxaban or a low molecular weight heparin (LMWH), alternatively oral anticoagulation.

Results

Between April?2004 and June?2005, the AO multicenter study at 11?European trauma centers included 313?patients (mean age 80.6?years, 77% women, 23% men) with 315?unstable trochanteric fractures treated with a Peroximal Femoral Nail Antirotation? (PFN???) device for consecutive follow-up [24]. In 82%, the fractures were 31-A2, while in 18% the fractures were 31-A3. Average operation time for A2 fractures was 56?min and 66?min for A3?fractures. Average duration of hospital stay in the trauma center was 12?days. Surgical reduction and fracture fixation that permitted full weight-bearing immediately after operation was achieved in 72% of cases. Of 165?complications, 46?were surgery-related with unplanned revision surgery in 28?cases (including 7?femur fractures and 4 acetabular penetrations). Follow-up for more than 1?year was possible in 56% of patients. After 1?year, 89% of the fractures were consolidated. The highest complication rate was found in fractures type 31-A2.3 and in patients older than 90?years. The recorded number of implant-related complications (14.6%) is comparable to the results of other intramedullary and extramedullary implants.     

The olecranon osteotomy provides better outcome than the triceps-lifting approach for the treatment of distal humerus fractures

Introduction

Intra-articular distal humeral fractures can be approached in a variety of ways. The purpose of this study is to evaluate and compare the functional outcomes of two approaches: approach with olecranon osteotomy and triceps-lifting approach for the treatment of intra-articular distal humeral fractures.

Methods

This study shows a consecutive series of 54 intra-articular distal humeral fractures of 54 patients who were treated with open reduction and internal fixation with anatomic plating. Lateral plating was performed in 10 (45.5 %) patients, and medial and lateral parallel plating was performed in 12 (54.5 %) patients in olecranon osteotomy group, while lateral plating was performed in 8 (25 %) patients, and medial and lateral parallel plating was performed in 24 (75 %) patients in triceps-lifting group.

Results

Mean follow-up was 38.3 months for olecranon osteotomy group and 41.4 months for triceps-lifting group. Functional outcomes according to MAYO elbow score and extension-flexion motion arc values were significantly better in olecranon osteotomy group (p < 0.05).

Conclusion

Approach with olecranon osteotomy provided better functional outcomes than triceps-lifting approach. Additionally, intra-articular distal humerus fractures can be safely treated with olecranon osteotomy which provides more control over the elbow joint and better visualisation and allows early postoperative rehabilitation.

Level of evidence

IV.