Buttress Reduction Research Articles

Evaluation of the clinical efficacy of using an inverted triangular cannulated compression screw in combination with positive or negative buttress reduction for the healing of femoral neck fractures

ObjectiveWe aimed to compare the clinical efficacy of inverted triangular cannulated compression screws combined with Gotfried positive or negative buttress reduction in the healing of femoral neck fractures.MethodsBetween October 2017 and March 2021, 55 patients with femoral neck fractures underwent treatment using inverted triangular cannulated compression screws combined with Gotfried positive or negative buttress reduction. Among these patients, 29 received inverted triangular cannulated compression screws combined with Gotfried positive buttress reduction treatment. This group consisted of 16 males and 13 females, with an average age of 43.45 ± 8.23 years. Additionally, 26 patients received inverted triangular cannulated compression nails combined with Gotfried negative buttress reduction treatment. This group included 14 males and 12 females, with an average age of 41.96 ± 8.69 years. Postsurgery, various measurements were taken, including the degree of shortening of the femoral neck, degree of bone nonunion, degree of fixation failure, degree of ischemic necrosis of the femoral head, and Harris score of the hip joint.ResultsAll patients were followed up for a minimum of 18 months. The group that underwent treatment with an inverted triangular cannulated compression screw combined with Gotfried positive buttress reduction did not experience any cases of bone nonunion, fixation failure, or ischemic necrosis of the femoral head. In the group that received treatment with inverted triangle cannulated compression screws combined with Gotfried negative buttress reduction, there was one case of bone nonunion, three cases of early fixation failure, and one case of ischemic necrosis. Ultimately, five patients (19.23% of the total) underwent joint replacement surgery. The average shortening lengths in the vertical plane were 4.07 ± 1.98 mm and 8.08 ± 3.54 mm, respectively. In the horizontal plane, the average shortening lengths were 3.90 ± 1.57 mm and 7.77 ± 3.31 mm, respectively. At the last follow-up, the group that received Gotfried positive buttress reduction had a greater Harris hip joint score.ConclusionThe success rate of combining inverted triangular cannulated compression screws with Gotfried positive buttress reduction surgery is relatively high. This surgical approach effectively prevents femoral neck shortening and improves hip joint function. Moreover, it is crucial to avoid negative buttress reduction when managing femoral neck fractures.

Sagittal support rather than medial cortical support matters in geriatric intertrochanteric fracture: A finite element analysis study

Hip fracture, increasing exponentially with age, is osteoporosis's most severe clinical consequence. Intertrochanteric fracture, one of the main types of hip fracture, is associated with higher mortality and morbidity. The current research hotspots lay in improving the treatment effect and optimizing the secondary stability after intertrochanteric fracture surgery. Cortex buttress reduction is a widely accepted method for treating intertrochanteric fracture by allowing the head-neck fragment to slide and rigidly contact the femoral shaft's cortex. Medial cortical support is considered a more effective option in treating young patients. However, osteo-degenerations features, including bone weakness and cortical thickness thinning, affect the performance of cortex support in geriatric intertrochanteric fracture treatment. Literature focusing on the age-specific difference in cortex performance in the fractured hip is scarce. We hypothesized that this osteo-19 degenerative feature affects the performance of cortex support in treating intertrochanteric fractures between the young and the elderly. We established twenty models for the old and the young with intertrochanteric fractures and performed static and dynamic simulations under one-legged stance and walking cycle conditions. The von Mises stress and displacement on the femur, proximal femoral nail anti-rotation (PFNA) implant, fracture plane, and the cutting volume of cancellous bone of the femur were compared. It was observed that defects in the anterior and posterior cortical bone walls significantly increase the stress on the PFNA implant, the displacement of the fracture surface, and cause a greater volume of cancellous bone to be resected. We concluded that ensuring the integrity and alignment of the anterior and posterior cortical bones is essential for elderly patients, and sagittal support is recommended. This finding suggests that the treatment method for intertrochanteric fracture may differ, considering the patient's age difference.

Biomechanical Stability of Femoral Neck System for Pauwels Type III Femoral Neck Fractures Based on Different Reduction Quality.

To further investigate the biomechanics of a femoral neck system (FNS) for Pauwels type III femoral fractures based on three different reductions.We constructed three different reduction (anatomical reduction, negative buttress reduction, and positive buttress reduction) models of Pauwels type III femoral neck fractures. Then, three cannulated screws (3CS), dynamic hip screws (DHS), dynamic hip screws combined with an anti-rotation screw (DHS + ARS), one-hole femoral neck system (1HFNS), and two-hole femoral neck system (2HFNS) were assembled with the reduction models, respectively, to simulate the internal fixation surgical procedure. All models had a load of 2100N in line with the femoral mechanical axis applied. The implant stress, the head and implant displacements, and the rotational angles of all models were recorded and analyzed.Compared to 3CS and 2HFNS, 1HFNS had higher implant stress (higher than 92.5MPa and 46.3MPa, respectively) and displacement (higher than 0.9mm and 0.8mm, respectively) in the anatomical reduction. 2HFNS exhibited the highest stress values (225.5MPa) in the anatomical reduction but the lowest values (159.8MPa) in the positive buttress reduction when compared to the other implants. 2HFNS showed the best rotational stability in the negative and positive buttress reduction (rotational angels of 0.8° and 0.6°, respectively).Based on the outcome of this computational study, it might be concluded that 2HFNS was an alternative fixation for the treatment of Pauwels type III femoral neck fracture, especially when anatomical reduction cannot be perfectly attained. More relevant clinical and biomechanical studies are needed in the future.

Clinical observation of Gofried positive buttress reduction in the treatment of young femoral neck fracture: A systematic review and meta-analysis.

Femoral neck fractures in young adults(<65 years), have always been a difficult problem, characterized by high rates of nonunion and avascular necrosis (AVN). The clinical efficacy of anatomical reduction and non-anatomical reduction methods needs to be supported by clinical data. Therefore, we conduct a meta-analysis on the clinical efficacy of different reduction methods to better guide clinical practice. Relevant studies published using internal fixation to treat femoral neck fracture in several databases were searched. The outcomes sought included Harris score and the rate of AVN, nonunion and femoral neck shortening (<5 mm). Included studies were assessed for methodological bias and estimates of effect were calculated. Potential reasons for heterogeneity were explored. The clinical results showed that compared with the anatomical reduction and positive buttress, there is no significant difference in the rate of AVN (OR = 0.87, 95%CI: 0.55-1.37, P = .55), nonunion (OR = 0.54, 95%CI: 0.21-1.41, P = .21), femoral neck shortening (<5 mm) (OR = 1.03,95%CI: 0.57-1.86, P = .92), the Harris score (MD = -0.28, 95%CI: -1.36-0.80, P = .61) and the excellent and good rate of Harris score (OR = 1.73, 95%CI: 0.84-3.56, P = .61). However, compared with negative buttress, the rate of AVN (OR = 0.62, 95%CI: 0.38-1.01, P = .05), nonunion (OR = 0.34, 95%CI: 0.12-1.00, P = .05) and femoral neck shortening (<5 mm) (OR = 0.27, 95%CI: 0.16-0.45, P < .00001) were significantly lower, and the Harris score (MD = 6.53, 95%CI: 2.55 ~ 10.51, P = .001) was significantly better in positive buttress. In the case of difficult to achieve anatomical reduction, for young patients (< 65 years) with femoral neck fracture, reduction with positive buttress can be an excellent alternative and negative buttress should be avoided as much as possible.

Nonanatomical reduction of femoral neck fractures in young patients treated with femoral neck system: a retrospective cohort study

PurposeNegative buttress reduction should be avoided in the treatment of femoral neck fractures (FNFs) using conventional fixation. As the femoral neck system (FNS) has been recently developed and utilized widely to treat FNFs, the association of reduction quality with postoperative complications and clinical function has not been clarified. The purpose of this study was to evaluate the clinical effect of nonanatomical reduction in young patients with FNFs treated with FNS.MethodsThis multicenter, retrospective cohort study included 58 patients with FNFs treated with FNS between September 2019 and December 2021. According to the reduction quality immediately following surgery, patients were classified into positive, anatomical, and negative buttress reduction groups. Postoperative complications were assessed with 12 months of follow-up. The logistic regression model was used to identify risk factors for postoperative complications. The postoperative hip function was assessed using the Harris hip scores (HHS) system.ResultsAt a follow-up of 12 months, a total of eight patients (8/58, 13.8%) had postoperative complications in three groups. Compared with the anatomical reduction group, negative buttress reduction was significantly associated with a higher complication rate (OR = 2.99, 95%CI 1.10–8.10, P = 0.03). No significant associations were found between positive buttress reduction and the incidence of postoperative complications (OR = 1.21, 95%CI 0.35–4.14, P = 0.76). The difference was not statistically significant in Harris hip scores.ConclusionNegative buttress reduction should be avoided in young patients with FNFs treated with FNS.

Biomechanical study of femoral neck system for young patients with nonanatomically reduced femoral neck fractures: a finite element

BackgroundA consensus regarding the optimal approach for treating femoral neck fractures is lacking. We aimed to investigate the biomechanical outcomes of Femoral Neck System (FNS) internal fixation components in the treatment of nonanatomically reduced femoral neck fractures.MethodWe constructed two types of femoral neck fractures of the Pauwels classification with angles of 30° and 50°, and three models of anatomic reduction, positive buttress reduction and negative buttress reduction were constructed. Subgroups of 1 to 4 mm were divided according to the distance of displacement in the positive buttress reduction and negative buttress reduction models. The von Mises stress and displacements of the femur and FNS internal fixation components were measured for each fracture group under 2100-N axial loads.ResultsWhen the Pauwels angle was 30°, the positive 1-mm and 2-mm models had lower FNS stress than the negative buttress model. The positive 3- and 4-mm models showed FNS stress similar to that of the negative buttress model. But the four positive buttress models had similar stresses on the femur as the negative buttress model. When the Pauwels angle was 50°, the four positive buttress models had higher FNS stress than the negative buttress model. Three positive buttress models (2 mm, 3 and 4 mm) resulted in lower stress of the femur than the negative buttress model, though the 1-mm model did not. When the Pauwels angle was 30°, the positive buttress model had a lower displacement of the FNS than the negative buttress model and a similar displacement of the femur with the negative buttress model. When the Pauwels angle was 50°, the positive buttress model had a higher displacement of the FNS and femur than the negative buttress model. Our study also showed that the von Mises stress and displacement of the internal fixation and the femur increased as the fracture angle increased.ConclusionFrom the perspectiveof biomechanics, when the Pauwels angle was 30°, positive buttress was morestable to negative buttress. However, when the Pauwels angle was 50°, this advantage weakens.In our opinion, the clinical efficacy of FNS internal fixation with positivebuttress may be related to the fracture angle, neck-shaft angle and alignmentin the lateral view. This result needs verification in further clinicalstudies.

Clinical observation and finite element analysis of cannulated screw internal fixation in the treatment of femoral neck fracture based on different reduction quality

ObjectiveFemoral neck fracture is one of the most common bone types. The effect of reduction quality on hip joint function and complications after screw internal fixation is not fully understood. To investigate the clinical efficacy and mechanical mechanism of positive buttress, anatomical reduction, and negative buttress in the treatment of femoral neck fracture after cannulated screw fixation.MethodsRetrospective analysis of patients with femoral neck fracture treated with three cannulated screws internal fixation in our hospital from January 2013 to December 2018. According to the quality of fracture reduction, the patients were divided into positive buttress group, anatomical reduction group, and negative buttress group. Basic information such as injury mechanism, time from injury to surgery, Garden classification and Pauwels classification was collected, Harris scores were performed at 3 months, 6 months, and 12 months after surgery, and postoperative complications (femoral head necrosis, femoral neck shortening, and femoral neck nonunion) were collected. At the same time, three groups of finite element models with different reduction quality were established for stress analysis, their stress clouds were observed and the average displacement and stress of the three groups of models were compared. P < 0.05 was used to represent a statistically significant difference.ResultsA total of 225 cases of unilateral femoral neck fractures were included and followed up for an average of 4.12 ± 0.69 years. There was no significant difference in age, gender, side, injury mechanism, time from injury to surgery, BMI, Garden classification, Pauwels classification, and follow-up time among the three groups (P > 0.05). However, there was significant difference in Harris score at 6 and 12 months after operation among the three groups (P < 0.05), which was higher in the positive buttress group and anatomical reduction group than in the negative buttress group. In addition, the incidence of osteonecrosis of the femoral head in the negative buttress group (32.2%) was greater than that in the anatomical reduction group (13.4%) and the positive buttress group (5.4%) (P < 0.05). In addition, the incidence of femoral neck nonunion and femoral neck shortening in the negative buttress group was also higher than that in the anatomical reduction positive buttress group (P < 0.05). The finite element results showed that the stress and fracture end displacement in the negative buttress group were greater than those in the positive buttress group (P < 0.05).ConclusionBoth positive buttress and anatomical reduction in the treatment of femoral neck fracture with cannulated screw internal fixation can obtain better clinical effect and lower postoperative complications. Positive brace support and anatomic reduction can limit the restoration of femoral stress conduction. Therefore, it is not necessary to pursue anatomical reduction too deliberately during surgery, while negative buttress reduction should be avoided.

Assessing the effect of Gotfried reduction with positive buttress pattern in the young femoral neck fracture

BackgroundAlthough many available surgical procedures for displaced femoral neck fractures in young patients, there are still many challenges to achieve satisfactory results. The incidence of avascular necrosis and nonunion rates remains relatively high despite the progress in our understanding and surgical technique. The purpose of this study was to evaluate the clinical efficacy of Gotfried reduction and cannulated screw fixation in the treatment of femoral neck fracture for young adults.MethodsA retrospective analysis was made on 67 cases from May 2013 to March 2019. They were divided into three groups according to the first postoperative anteroposterior view of hip X-ray: Anatomic reduction (group A), Gotfried positive buttress reduction (group B), and Gotfried negative buttress reduction (group C). The incidence of avascular osteonecrosis of the femoral head (AVN) and the Harris scores of hip joints were compared in three groups at the last follow-up.ResultsThe mean follow-up period after surgery was 22.5 ± 11.3 (range, 11–34) months. There were 21 cases (mean age, 49.7 ± 11.6) in group A, 24 cases (mean age, 48.6 ± 11.3) in group B, 22 cases (mean age, 48.3 ± 12.4) in group C. No significant difference in general preoperative demographics (P > 0.05). The incidence of avascular necrosis of femoral head in group A, B, and C was 19.05%, 20.83%, and 22.73%, respectively, showing no significant difference between groups (P = 0.156). The mean Harris hip scores at the final follow-up for groups A (85.6 ± 6.7) and B (84.5 ± 6.2) were significantly higher than group C (74.3 ± 8.3), and the difference was statistically significant (P = 0.043). The incidence of femoral neck shortening in group A and group B was significantly lower than that in group C in postoperative 1 year, and the difference was statistically significant (P < 0.05).ConclusionsGotfried positive buttress reduction and fixation for femoral neck fracture may lead to similar clinical results with anatomic reduction, but much better than Gotfried negative buttress reduction. For the patients of femoral neck fracture with severe displacement and difficulty reduction, it is not necessary to pursue anatomical reduction. Achieving positive valgus reduction can also obtain satisfactory clinical results, and should try to avoid negative buttress.

Fracture neck femur during COVID pandemic valgus reduction for osteosynthesis (inferior calcar buttress reduction)

Fracture neck femur following high velocity injury is likely to increase after resumption of vehicular traffic and other day to day activities including fall from height, sporting injuries etc. In this covid era, in a positive covid scenario in a patient, surgery should preferably be deferred till four weeks, by which time the “second cytokine storm” response settles down. In a covid negative scenario also, the patient subsequently developing covid positive is a definite possibility. In displaced unstable fracture neck femur, osteosynthesis can be contemplated because of factors present in the fracture and surgeon’s preference requiring emergency intervention since earliest surgical intervention will prognosticaly give better results in terms of union. This study emphasises on inferior calcar buttress reduction with positive cortical apposition and reverse triangular design of conventional cancellous screw fixation as contributory factors to sustainable reduction and union. Keywords: Fracture neck femur, Valgus reduction, Osteosynthesis, Cancellous screw, Union, Stress, Reduction, Conventional fixation, Covid, Cytokine reaction and storm

Image study of anteromedial cortical morphology of intertrochanteric fractures

To study the anteromedial cortical morphology of intertrochanteric fracture with CT three-dimensional reconstruction technique, and to provide a reference for further study of cortical buttress reduction theory. CT data of 75 patients with unstable intertrochanteric fracture with complete imaging data treated between January 2016 and January 2019 were retrospectively analyzed, including 32 males and 43 females, aged 65-98 years (mean, 79.8 years). According to AO/Orthopaedic Trauma Association typing of 2018 edition, there were 46 cases of 31-A2.2 type and 29 cases of 31-A2.3 type. The image processing techniques such as segmentation modeling and virtual reset were performed. The thickness of the cortex at the anteromedial corner, the angle between the anterior wall fracture line and the coronal horizontal line, the angle between the medial wall fracture line and the sagittal horizontal line, the width of the cortex supported by the medial wall were measured, and the morphology of the cortical bone at the anteromedial corner were observed. The angle between the anterior wall fracture line and the coronal horizontal line was 51.8-72.6°, with an average of 62.4°; the angle between the medial wall fracture line and the sagittal horizontal line ranged from 17.6° to -47.3°, with an average of -15.8°; the thickness of the cortex at the anteromedial angle was 3.6-6.1 mm, with an average of 4.4 mm; and the width of the cortex supported by the medial wall was 14.3-21.2 mm, with an average of 16.8 mm. The morphology of the cortical bone at the anteromedial corner had 3 forms: angle with femoral neck axis >90°, 57 cases (76.0%); perpendicular to femoral neck axis, 7 cases (9.3%); angle with femoral neck axis <90° (including reverse angle), 11 cases (14.7%). CT three-dimensional reconstruction can clearly show the cortical morphology and the direction of the fracture line of intertrochanteric fracture, which can indicate the stability of the intertrochanteric fracture after reduction, and has a good guiding on the form of cortical buttress reduction.

Inferior calcar buttress reduction pattern for displaced femoral neck fractures in young adults: a preliminary report and an effective alternative

BackgroundFracture reduction quality is of paramount importance for osteosynthesis. The aim of this study was to report the outcome of an inferior cortical buttress non-anatomic reduction pattern and internal fixation for displaced femoral neck fractures (Garden types III and IV) in young adults.MethodsA retrospective analysis of 46 displaced femoral neck fractures was performed, which were treated by closed reduction and internal fixation with parallel cannulated screws. There were 20 males and 26 females, with an average age of 50.3 years (19–60). According to the inferior cortical reduction quality seen in recorded intraoperative fluoroscopy, the patients were divided into two groups. Group I (n = 30) was anatomic cortical apposition as the two inferior cortices were smoothly contacted, and group II (n = 16) was buttress cortical apposition as the two inferior cortices were located in positive support contact (Gotfried reduction pattern). With a mean follow-up of 22.0 months, femoral neck length, neck–shaft angle, and clinical outcomes were compared.ResultsThirty-nine patients (84.8%) achieved uneventful fracture union. Complications occurred in seven patients, six in group I (20%) and one in group II (6.3%), including displacement to varus, neck shortening, early fixation failure, nonunion, and avascular necrosis of the femoral head. No significant difference existed in the complication rate between the two groups (p = 0.216). Four patients (13.3%) in group I were converted to prosthetic replacement, but none in group II.ConclusionsFor closed reduction and fixation of displaced femoral neck fractures in young adults, an inferior cortical buttress reduction pattern, though non-anatomic, can produce sustainable fracture stability and predictable clinical outcomes.

The Gotfried (Nonanatomic, Closed) Reduction of Unstable Subcapital Femoral Fractures

A nonanatomic reduction of displaced—unstable subcapital femoral fractures has been described. The rationale of this approach is based on biomechanical consideration. Definitions used in this method include: negative buttress—in which the lower medial edge of the proximal fracture part (femoral neck and head) is protruding medially to the upper medial edge of the distal femoral neck part; positive buttress—in which the upper medial edge of the distal femoral neck part is protruding medially to the distal medial edge of the proximal fracture part. Because observations have shown that negative buttress is associated with a higher failure rate of reduction, negative buttress should be avoided. Negative buttress allows easier displacement of the reduced femoral head into the varus; positive buttress acts in the opposite way. Hence, the goal of the Gotfried reduction is to create a positive buttress reduction while at the same time reduce the fracture in the valgus. With the patient positioned on a fracture table, the procedure includes 3 stages: (1) desimpaction; (2) reduction; and (3) reconstruction. The author uses this technique when preservation of the femoral head, after subcapital fractures, is desired.