Garden Classification Research Articles

Femoral neck fractures: a cohort comparison of nonunion and complication rates after ballistic versus blunt mechanism fractures.

This study aims to review complications and union rates of ballistic femoral neck fractures when compared to their blunt counterparts. We hypothesize that gunshot injuries to the femoral neck may have higher rates of complications (nonunion, avascular necrosis [AVN], and implant failure) as a result of increasing comminution and disruption to the already tenuous blood supply through the femoral neck. Following the Institutional Review Board approval, a retrospective chart review was performed identifying femoral neck fractures at a single level 1 trauma center from 2018 to 2023. Inclusion criteria were age 16-45years old with intracapsular femoral neck fractures. Exclusion criteria were absence of radiographic and clinical follow-up beyond 6 weeks, prior femur fractures, pathologic fractures, or primary surgery of total hip arthroplasty. Garden classification and Pauwels angle were reported. Clinical union was defined as the absence of painwith ambulation in the absence of radiographic changes. Radiographic union was defined using the validated Radiographic Union Score for Hip (RUSH) scoring system. Complication rates (deep and superficial infection, failure of fixation, and AVN) and subsequent surgery were recorded. After exclusion, 12ballistic and 16 blunt femoral neck fractures met inclusion criteria and were reviewed. The ballistic cohort had significant more Garden I fractures than the blunt cohort (4 [33%] vs. 0 [0%]), and significantly fewer Garden IV fractures than the blunt cohort (2 [17%] vs. 9 [56%]). Despite different Garden classification types of fracture patterns, the Pauwels angle between the two cohorts was similar (51° ballistic vs. 60° blunt, p = 0.16). The overall nonunion rate was 24.1%. Nonunion rates were similar between the two cohorts (3, 25% ballistic vs. 4, 25% blunt, p = 0.99). The mean final RUSH score between the two cohorts was similar (20.1ballistic vs. 23.4 blunt [p = 0.05]). The total complication rate was 31% (9/28) consisting of 7 nonunions and 2 malunions across both cohorts. The current study found no difference in the union rates between blunt and ballistic femoral neck fractures. Although comparing these fractures using traditional classification systems (Garden and Pauwels) are difficult due to the inherent differences in mechanism and the applicability of these tools, both groups presented with high rates of nonunion and complications. We believe the similar RUSH scores and complication rates in both cohorts show these fractures fundamentally behave similarly and remain challenging injuries to manage with ORIF.

Short-term effectiveness of robot-guided femoral neck system combined with cannulated compression screw fixation in treatment of femoral neck fracture in young and middle-aged patients

To investigate short-term effectiveness of robot-guided femoral neck system (FNS) combined with cannulated compression screw (CCS) fixation in treatment of femoral neck fracture in young and middle-aged patients. A clinical data of 49 young and middle-aged patients with femoral neck fractures, who met the selection criteria and admitted between January 2021 and June 2023, was retrospectively analyzed. After reduction of femoral neck fractures, 27 cases were treated with robot-guided FNS fixation (FNS group) and 22 cases with robot-guided FNS and CCS fixation (FNS+CCS group). There was no significant difference in baseline data such as gender, age, cause of fracture, time from fracture to operation, fracture side, and classification (Garden classification and Pauwels classification) between the two groups ( P>0.05). The operation time, intraoperative blood loss, intraoperative fluoroscopy frequency, the time when the patient began bearing weight, and hip joint pain and functional scores (VAS score and Harris score) at last follow-up for two groups were recorded. Imaging re-examination was taken to evaluate the quality of fracture reduction, fracture healing, as well as the occurrence of fracture non-union, osteonecrosis of the femoral head, and femoral neck shortening. All operations were successfully completed and the incisions healed by first intention. There was no significant difference in operation time and intraoperative blood loss between the two groups ( P>0.05), and the intraoperative fluoroscopy frequency in FNS+CCS group significantly increased compared to FNS group ( P<0.05). All patients were followed up 12-18 months (mean, 14.1 months). Imaging re-examination showed that there was no significant difference in fracture reduction quality between the two groups ( P>0.05), but the fracture healing time was significantly shorter in FNS+CCS group than in FNS group, and weight-bearing began earlier ( P<0.05). The incidences of femoral neck shortening, fracture non-union, and osteonecrosis of the femoral head were lower in FNS+CCS group than in FNS group, and there was significant difference in the incidence of femoral neck shortening between groups ( P<0.05). At last follow-up, there was no significant difference in VAS scores between the two groups ( P>0.05). However, the Harris score was significantly higher in FNS+CCS group than in FNS group ( P<0.05). Compared with FNS fixation alone, robot-guided FNS combined with CCS fixation in the treatment of femoral neck fractures in young and middle-aged patients has obvious advantages in terms of early weight bearing and fracture healing, improves fracture healing rate, effectively prevents postoperative complications, and can obtain good short-term effectiveness.

Investigation of Novel Radiological Parameters to Predict Treatment Failure and Ideal Surgical Interventions in Young Femoral Neck Fractures Treated with Triple Cannulated Screw: A Retrospective Analysis.

Treatment failure remains a challenge in young femoral neck fractures treated with triple cannulated screws (TCS). This study aims to identify novel radiological parameters that can predict treatment failure and propose surgical techniques to enhance the success of TCS or aid in selecting alternative methods. We conducted a retrospective analysis of 87 patients who underwent surgery for femoral neck fractures between February 2014 and June 2022, meeting the inclusion criteria. Patients achieving union were categorized as Non-Fail (Group 1), while those experiencing nonunion were categorized as Fail (Group 2). Various demographic and clinical factors were assessed, including age, gender, fracture side, and fracture classification (Garden and Pauwels). Radiological parameters such as fragmentation in the medial cortex, postoperative fracture displacement in the calcar region, collo-diaphyseal angle (CDA) difference (varus/valgus alignment), and several newly defined parameters (modified tip apex distance (m-TAD), tip cortex distance (TCD), upper-lower screw-cortex distance/neck diameter, the calcar screw-cortex distance/neck diameter (Buyukdogan index), and sub-capital area/basocervical area (Dogan index) were evaluated. Patients developing nonunion were studied to establish potential cut-off values based on radiological parameters. Of the patients, 61 were classified as Non-Fail (Group 1) and 26 as Fail (Group 2). Both groups exhibited similar distributions in terms of gender, fracture side, Pauwels classification, and follow-up times (p > 0.05). However, Group 2 had a higher mean age than Group 1 (p = 0.006). There was a significant difference between the two groups in terms of Garden classification (p = 0.0003). Furthermore, postoperative calcar displacement, varus alignment, m-TAD, TCD, upper-lower screw-cortex distance/neck diameter ratio, Buyukdogan index, and Dogan index showed significant differences between the groups (p < 0.05). Conversely, medial calcar fragmentation did not differ significantly between the groups (p > 0.05). The Dogan index (≤ 0.5) can serve as an independent preoperative predictor of treatment failure, aiding in the selection of more effective surgical interventions than TCS. Varus alignment (> 10 degrees), the upper-lower screw-cortex distance to the neck diameter (> 0.45) and Buyukdogan index (> 0.2) are influenced by the surgical technique of TCS application and should be considered to decrease the success of TCS.

Comparison of dynamic hip screw with anti-rotation screw and femoral neck system internal fixation for the treatment of garden II-IV type femoral neck fractures.

Femoral neck fractures, which are fractures occurring from the femoral head to the base of the femoral neck, are prevalent in the elderly population. With the progression of societal aging, the incidence of femoral neck fractures has been steadily increasing, making it a significant global issue that urgently needs to be addressed. To compare the efficacy and safety of dynamic hip screw (DHS) with anti-rotation screw and femoral neck system (FNS) internal fixation for the treatment of Garden II-IV type femoral neck fractures. A total of 90 patients with Garden II-IV type femoral neck fractures were randomly assigned to either the control group (n= 45) treated with DHS and anti-rotation screw or the experimental group (n= 45) treated with FNS. Surgical outcomes, including incision size, blood loss, operation time, fluoroscopy frequency, and fracture healing time, were compared. Postoperative complication rates, reoperation rates, Harris scores, and visual analogue scale (VAS) scores were also assessed. The experimental group demonstrated significantly reduced incision length, blood loss, operation time, and fluoroscopy frequency compared to the control group (P< 0.01). No significant differences were observed in fracture healing time, Garden classification, or fracture reduction outcomes between the two groups (P> 0.05). At 6 months post-treatment, both groups showed significant improvements in Harris scores and VAS scores compared to pre-treatment (P< 0.05), with no significant differences between the groups (P> 0.05). The rates of internal fixation failure, nonunion, and avascular necrosis of the femoral head, as well as overall incidence of postoperative complications and reoperation rates, showed no significant differences between the two groups (P> 0.05). Both DHS with anti-rotation screw and FNS internal fixation demonstrated comparable efficacy and safety profiles in the treatment of Garden II-IV type femoral neck fractures. The experimental group showed advantages in terms of reduced incision length, blood loss, operation time, and fluoroscopy frequency, while maintaining similar clinical outcomes and complication rates.

Relationship between preoperative psychological stress and short-term prognosis in elderly patients with femoral neck fracture

BACKGROUND Older adults are at high risk of femoral neck fractures (FNFs). Elderly patients face and adapt to significant psychological burdens, resulting in different degrees of psychological stress response. Total hip replacement is the preferred treatment for FNF in elderly patients; however, some patients have poor postoperative prognoses, and the underlying mechanism is unknown. We speculated that the postoperative prognosis of elderly patients with FNF may be related to preoperative psychological stress. AIM To explore the relationship between preoperative psychological stress and the short-term prognosis of elderly patients with FNF. METHODS In this retrospective analysis, the baseline data, preoperative 90-item Symptom Checklist score, and Harris score within 6 months of surgery of 120 elderly patients with FNF who underwent total hip arthroplasty were collected. We analyzed the indicators of poor short-term postoperative prognosis and the ability of the indicators to predict poor prognosis and compared the correlation between the indicators and the Harris score. RESULTS Anxiety, depression, garden classification of FNF, cause of fracture, FNF reduction quality, and length of hospital stay were independent influencing factors for poor short-term postoperative prognoses in elderly patients with FNF (P &lt; 0.05). The areas under the curve for anxiety, depression, and length of hospital stay were 0.742, 0.854, and 0.749, respectively. The sensitivities of anxiety, depression, garden classification of FNF, and prediction of the cause of fracture were 0.857, 0.786, 0.821, and 0.821, respectively. The specificities of depression, FNF quality reduction, and length of hospital stay were the highest at 0.880, 0.783, and 0.761, respectively. Anxiety, depression, and somatization scores correlated moderately with Harris scores (r = -0.523, -0.625, and -0.554; all P &lt; 0.001). CONCLUSION Preoperative anxiety, depression, and somatization are correlated with poor short-term prognosis in elderly patients with FNF and warrant consideration.

Comparison of effectiveness of three surgical methods in treatment of Pauwels type Ⅲ femoral neck fracture in young and middle-aged patients

To compare the effectiveness of three surgical methods in the treatment of Pauwels type Ⅲ femoral neck fracture in young and middle-aged patients, in order to provide reference for clinical selection of appropriate surgical methods. The clinical data of 103 patients with Pauwels type Ⅲ femoral neck fracture who met the selection criteria between June 2018 and December 2021 were retrospectively analyzed. The fractures were fixed with hollow screws in an inverted triangular shape (37 cases, hollow screw group), hollow screws in an inverted triangular shape combined with eccentric shaft screw (34 cases, eccentric shaft screw group), and hollow screws in an inverted triangular shape combined with medial support plate (32 cases, support plate group). There was no significant difference in age, gender, cause of injury, body mass index, time from injury to operation, side of the fracture, and Garden classification, whether they were in traction preoperatively, and other baseline data between groups ( P>0.05). The operation time, intraoperative blood loss, the number of fluoroscopy, the length of hospital stay, early postoperative complication and postoperative weight-bearing time of the three groups were recorded. Harris score was used to evaluate joint function at 6 and 12 months after operation, and the difference between the two time points (change value) was calculated for comparison between groups. X-ray films were reviewed to evaluate the quality of fracture reduction (Garden index) and healing, as well as the occurrence of internal fixation failure and femoral head necrosis. The patients of the three groups were successfully completed. Compared with the hollow screw group and the eccentric shaft screw group, the operation time and intraoperative blood loss of the support plate group significantly increased, the number of fluoroscopy reduced, and the quality of fracture reduction was better, the differences were significant ( P<0.05). The operation time, intraoperative blood loss, and the number of fluoroscopy of the hollow screw group were less than those of the eccentric shaft screw group, the differences were significant ( P<0.05). There was no significant difference in the length of hospital stay between groups ( P>0.05). All patients in the three groups were followed up 21-52 months, with an average follow-up time of 36.0 months, and there was no significant difference between groups ( P>0.05). The incisions of all patients healed by first intention. Imaging reexamination showed that there was no significant difference in the incidence of fracture nonunion between groups ( P>0.05). The fracture healing, partial weight-bearing, and full weight-bearing were significantly earlier in the eccentric shaft screw group and the support plate group than in the hollow screw group ( P<0.05). There was no significant difference in change value of Harris score, the incidence of postoperative deep venous thrombosis and femoral head necrosis between groups ( P>0.05); however, the incidence of internal fixation failure in the support plate group and the eccentric shaft screw group was significantly lower than that in the hollow screw group ( P<0.05). The incidence of postoperative lateral thigh irritation in the support plate group was significantly lower than that in the hollow screw group ( P<0.05); there was no significant difference between the eccentric shaft screw group and the other two groups ( P>0.05). The overall incidences of postoperative complications in the eccentric shaft screw group and the support plate group were significantly lower than that in the hollow screw group ( P<0.05). For young and middle-aged patients with Pauwels type Ⅲ femoral neck fracture, compared with simple hollow screw fixation in an inverted triangular shape, combined with medial support plate or eccentric shaft screw internal fixation can shorten the fracture healing time, reduce the incidences of postoperative complication, more conducive to early functional exercise of the affected limb; at the same time, the operation time and blood loss of combined eccentric shaft screw internal fixation are less than those of combined medial support plate internal fixation, so the hollow screw in an inverted triangular shape combined with eccentric shaft screw fixation may be a better choice.

The small screw-apex distance is potentially associated with femoral head osteonecrosis in adults with femoral neck fractures treated by closed reduction and percutaneous 3 parallel cannulated screws

ObjectiveFemoral neck fractures (FNFs) are among the most common fractures in elderly individuals. Surgery is the main treatment for FNFs, and osteonecrosis of the femoral head (ONFH) is one of the unacceptable complications. This study aimed to assess both the clinical and radiological outcomes in patients with FNFs treated with three parallel cannulated screws and to identify relationship between screws position and ONFH.Patients and methodsA total of 100 patients who were treated with closed reduction and fixed with 3 parallel cannulated screws met the inclusion criteria between January 2014 and December 2020 at authors’ institution. The follow-up duration, age, sex, affected side, and injury-to-surgery interval were collected; the neck-shaft angle of both hips, screw-apex distance (SAD) and the tip-apex distance (TAD)were measured; and the Garden classification, quality of reduction and presence of ONFH were evaluated.ResultsThe sample consisted of 37 males and 63 females, with 60 left and 40 right hips affected. The mean age of patients was 54.93 ± 12.24 years, and the mean follow-up was 56.3 ± 13.38 months. The overall incidence of ONFH was 13%. No significant difference was observed in the incidence of ONFH by affected side, age, fracture displacement, injury-to-surgery interval, neck-shaft angle deviation, or reduction quality. The SAD was significantly shorter in ONFH patients than in normal patients for all three screws (p = 0.02, 0.02, and 0.01, respectively).ConclusionsThe short SAD of all screws is associated with femoral head necrosis of FNFs treated with 3 cannulated screws. The short SAD indicated that screws malpositioning in the weight-bearing area of the femoral head, potentially harming the blood supply and compromising the anchorage of the primary compressive trabeculae in this region.

Pre-sliding of the femoral neck system to prevent postoperative shortening of femoral neck fractures

ObjectiveThe purpose of this study is to evaluate the effect of pre-sliding of the femoral neck system (FNS) in the prevention of postoperative femoral neck shortening in femoral neck fractures. MethodThis study was designed to retrospectively analyze data from 109 patients with femoral neck fractures who were admitted to a Level I trauma center between April 2020 and June 2022. Of these patients, 90 were followed up for more than 12 months. The study included 52 males and 38 females, with 35 cases of Garden I and II fractures and 55 cases of Garden III and IV fractures. The Harris Hip Score at 12 months postoperatively were recorded. The patients were divided into two groups based on their surgical records and postoperative radiography: the Pre-sliding group and the No-pre-sliding group. The purpose of this study is to analyze the role of pre-sliding in preventing femoral neck shortening, fracture healing time, degree of postoperative shortening, complications, and Harris Hip Score, and to make a comparison between the two groups. ResultsAll 90 patients were followed up for over one year after surgery. A statistically significant difference was observed in the preoperative Garden classification (P < 0.05). At 1 year after the operation, the shortening distance was 6.5 ± 6.4 mm in the No-pre-sliding group and 3.9 ± 3.4 mm in the Pre-sliding group. The Harris Hip Score were 88.7 (79.8, 93.5) in the No-pre-sliding group and 94.8 (87.7, 96.9) in the Pre-sliding group, with a statistically significant difference between the two groups (P < 0.05). Shortening was concentrated at 3 months postoperatively and reached a stable state within 6 months, with less persistent shortening occurring after 6 months. There was no statistically significant difference in the preoperative baseline data. ConclusionPre-sliding of the FNS prevents postoperative shortening of the femoral neck and improves hip function as measured by the Harris Hip Score.

Revision ratio after Femoral Neck System implantation for hip fracture treatment: a retrospective cohort analysis.

The aim of the study is to determine the revision ratio after implantation of the femoral neck system (FNS) for the treatment of femoral neck fractures. A retrospective single center cohort analysis with a total of 71 patients who underwent the implantation of the FNS between December 2019 and December 2021, was performed. 31 males and 40 females were included. There was no exclusion based on BMI, ASA score, Garden classification or Pauwels classification. Primary outcome was the revision rate after FNS implantation. Secondary outcomes comprise the reason for revision surgery as well as the time toward revision surgery and the 30-day mortality. The revision ratio was 11 out of 71 patients (15.5%) with an average time to revision surgery of 10 months. Most common reason for revision was avascular necrosis (AVN) in 45.5%. Other reasons for revision surgery were implant failure due to a secondary fall on to the hip with the FNS implant in place, cut-out, cut-through and malunion in respectively 27.3%, 9%, 9% and 9% of the revision patients. The one- hole plate was used in 72% of the patients. Mean follow-up was 18.07 months (range 6-30 months). Full weight bearing instruction was given to 85.9% of the patients. Partial weight bearing in 14.1% of the patients. In conclusion, the FNS has similar revision ratio when used for femoral neck fractures compared to cannulated screw fixation in literature. The predominant reason for revision is AVN and implant failure with no difference between the use of the one- or-two-hole plate in this study.

Outcome of dynamic locked plate in treatment of intracapsular femur neck fracture

Background: The ideal surgical treatment of femoral neck fractures is still debatable. When internal fixation is used, many implants are available. This study aimed to evaluate the outcome following fixation of intracapsular femur neck fractures using the Targon-FN system (B. Braun, AG. Melsungen, Germany) comparing the results with a similar study done by the manufacturer and to assess risk factors associated with complications. Methods: A prospective interventional case series involved 30 consecutive patients aged from 23 to 82 (Mean 49 years) treated at Al-Jalaa trauma hospital in Benghazi- Libya in period from January 2016 to July 2017, for an intracapsular femur neck fracture with Targon-FN system. According to Garden classification 9 fractures (30%) undisplaced and 21 (70%) were displaced fractures, with 2 patients (6.7%) had type I, 7 patients (23.3%) had type II, 7 patients (23.3%) had type III and 14 patients (46.7%) had type IV fracture. Epidemiological data were collected. Patients were followed-up for 2 years (average 16 months). Joint function was assessed clinically by using Harris hip score (HHS) and fracture healing by radiological assessment at sex weeks, 3 months, 6 months, 1 year and finally at 2 years. Complications were recorded. Statistical analysis done to predict risk factors associated with reoperation and complications. Results: Sixteen patients (53.3%) developed one or more complications. Complications were higher than those of manufacturer’s study and included avascular necrosis (53.3%, n=16), nonunion (30%, n=9), blown out implant (16.66%, n=5), loosening screw (3.3%, n=1), and deep infection (3.3%, n=1). In total, 5 patients required total hip replacements. At end of 2 years 19 patients (63%) had poor result, one patient (3.3%) had fair result, 1 patient (3.3%) had good result and 9 patients (30%) had excellent result according to HHS. Delayed surgery, fracture displacement, surgeon’s experience, age ≥40 years and time to postop weight bearing recognized as risk factors for complications. Conclusions: A minimally-invasive surgery of Targon FN justifies use of this system for the preservation of the patient’s hip joint, early rehabilitation and mobilization. Complications and re-operation could be minimized by performing surgery within 24-48 hours, provision of skillful surgeons, and proper timing of postoperative weight bearing. The main limitation is the small number of cases and short follow-up averaged at 16 months.

Bipolar hip arthroplasty using conjoined tendon preserving posterior lateral approach in treatment of displaced femoral neck fractures.

Hip fractures account for 23.8% of all fractures in patients over the age of 75 years. More than half of these patients are older than 80 years. Bipolar hemiarthroplasty (BHA) was established as an effective management option for these patients. Various approaches can be used for the BHA procedure. However, there is a high risk of postoperative dislocation. The conjoined tendon-preserving posterior (CPP) lateral approach was introduced to reduce postoperative dislocation rates. To evaluate the effectiveness and safety of the CPP lateral approach for BHA in elderly patients. We retrospectively analyzed medical data from 80 patients with displaced femoral neck fractures who underwent BHA. The patients were followed up for at least 1 year. Among the 80 patients, 57 (71.3%) were female. The time to operation averaged 2.3 d (range: 1-5 d). The mean age was 80.5 years (range: 67-90 years), and the mean body mass index was 24.9 kg/m2 (range: 17-36 kg/m2). According to the Garden classification, 42.5% of patients were type Ⅲ and 57.5% of patients were type Ⅳ. Uncemented bipolar hip prostheses were used for all patients. Torn conjoined tendons, dislocations, and adverse complications during and after surgery were recorded. The mean postoperative follow-up time was 15.3 months (range: 12-18 months). The average surgery time was 52 min (range: 40-70 min) with an average blood loss of 120 mL (range: 80-320 mL). The transfusion rate was 10% (8 of 80 patients). The gemellus inferior was torn in 4 patients (5%), while it was difficult to identify in 2 patients (2.5%) during surgery. The posterior capsule was punctured by the fractured femoral neck in 3 patients, but the conjoined tendon and the piriformis tendon remained intact. No patients had stem varus greater than 3 degrees or femoral fracture. There were no patients with stem subsidence more than 5 mm at the last follow-up. No postoperative dislocations were observed throughout the follow-up period. No significance was found between preoperative and postoperative mean Health Service System scores (87.30 ± 2.98 vs 86.10 ± 6.10, t = 1.89, P = 0.063). The CPP lateral approach can effectively reduce the incidence of postoperative dislocation without increasing perioperative complications. For surgeons familiar with the posterior lateral approach, there is no need for additional surgical instruments, and it does not increase surgical difficulty.

Orthopaedic robot assisted closed reduction and cannulated screw internal fixation for the treatment of femoral neck fractures

To investigate the preliminary clinical effect of closed reduction and cannulated nail internal fixation for femoral neck fracture assisted by robot navigation and positioning system. From July 2019 to January 2020, 16 cases of femoral neck fracture （navigation group） were treated with closed reduction and internal fixation guided by robot system, including 7 males and 9 females, aged 25 to 72 years old with an average of （53.61±5.45） years old；Garden classification of fracture：3 cases of typeⅠ, 3 cases of typeⅡ, 8 cases of type Ⅲ, 2 cases of type Ⅳ. Non navigation group （control group）：20 cases of femoral neck fracture were treated with closed reduction and hollow nail internal fixation, 8 males and 12 females, aged 46 to 70 years old with an average of （55.23±4.64） years old；Garden typeⅠin 2 cases, typeⅡin 4 cases, type Ⅲ in 11 cases, type Ⅳ in 3 cases. The operation time, fluoroscopy times, guide needle drilling times, screw adjustment times, intraoperative bleeding volume and other indicators of two groups were evaluated. Both groups were followed up for 12 to 18 months with an average of （15.6±2.8） months. The fractures of both groups were healed without delayed union and nonunion. There was no significant difference in healing time between two groups（P=0.782）. There was no significant difference in Harris scores between two groups at the last follow-up（P=0.813）. There was no significant difference in operation time between two groups（P>0.05）. There were significant differences between two groups in fluoroscopy times, guide needle drilling times, hollow screw replacement times, and intraoperative bleeding volume（P<0.05）. Closed reduction and hollow screw internal fixation assisted by robot navigation system for femoral neck fracture has the advantages of minimally invasive operation, precise screw placement, and reduction of X-ray radiation damage during operation.

Management of Garden-I and II Femoral Neck Fractures: Perspectives on Primary Arthroplasty.

This review compares internal fixation versus arthroplasty in the treatment of nondisplaced femoral neck fractures (FNFs) calling attention to evolving areas of consensus that influence clinical decision-making. The Garden classification system, typically dichotomized into nondisplaced (types I and II) and displaced (types III and IV) fractures, has been used as a guide for surgical decision-making. Conventionally, treatment of nondisplaced FNF in the elderly has been with internal fixation, and treatment of a displaced FNF has been hemi-, or more recently total hip, arthroplasty. Studies over the last decade have raised concern over the appropriate treatment of nondisplaced FNFs due to high rates of reoperation of nondisplaced FNFs treated with internal fixation. Avascular necrosis (AVN), failure of internal fixation, secondary malunion, and pin/nail penetration through the femoral head have all been observed. Several studies have attributed fixation failure to a degree of femoral neck tilt ≥20°, either posteriorly or anteriorly as seen on the lateral X-ray. Because of these observations of fixation failures, the suggestion has been made that arthroplasty be used when the degree of posterior tilt exceeds a threshold of ≥20° tilt with the expectation of diminishing failure of fixation, decreasing the risk of reoperation and preserving function without increasing mortality rate. Frustrating additional analyses are uncertainties over the mechanisms of failure of internal fixation with ≥20° tilt and the persistently substantial 1-year mortality rate after FNF, which has not been influenced by fixation or replacement type. Due to the lack of consensus regarding the determination of the appropriate surgical intervention for nondisplaced FNFs, an improved algorithm for surgical decision-making for these fractures may prove useful.

Early effectiveness of Ti-Robot assisted femoral neck system for minimally invasive treatment of elderly Garden type Ⅱ and Ⅲ femoral neck fractures

To investigate the early effectiveness of the Ti-Robot assisted femoral neck system (FNS) in the treatment of elderly Garden type Ⅱ and Ⅲ femoral neck fractures. A retrospective analysis was conducted on the clinical data of 41 elderly patients with Garden type Ⅱ and Ⅲ femoral neck fractures who were admitted between December 2019 and August 2022 and met the selection criteria. Among them, 21 cases were treated with Ti-Robot assisted FNS internal fixation (study group), and 20 cases were treated solely with FNS internal fixation (control group). There was no significant difference in baseline data, including gender, age, side, cause of injury, time from injury to surgery, fracture Garden classification, and fracture line classification, between the two groups ( P>0.05). Surgical effectiveness was evaluated based on parameters such as operation time (including incision time and total operation time), reduction level, number of dominant pin insertions, intraoperative fluoroscopy frequency, incision length, whether to extend the incision, need for assisted reduction, postoperative hospital stay, fracture healing time, incidence of osteonecrosis of the femoral head, postoperative visual analogue scale (VAS) score at 1 day, and Harris hip score at last follow-up. The study group showed significantly shorter incision time, fewer dominant pin insertions, fewer instances of extended incisions, fewer intraoperative fluoroscopy frequency, and smaller incisions than the control group ( P<0.05). There was no significant difference in total operation time, reduction level, and assisted reduction frequency between the two groups ( P>0.05). Both groups achieved primary wound healing postoperatively, with no complications such as incision leakage or skin infection. All patients were followed up 12-24 months with an average of 14.6 months. Fractures healed in both groups, with no significant difference in healing time ( P>0.05). There was no significant difference in postoperative hospital stay between the two groups ( P>0.05). The study group showed significantly better VAS score at 1 day after operation and Harris hip score at last follow-up when compared to the control group ( P<0.05). No complication such as internal fixation failure, fracture displacement, or hip joint varus occurred in both groups during the follow-up. Osteonecrosis of the femoral head occurred in 1 patient of the control group, while no was observed in the study group, and the difference in the incidence of osteonecrosis of the femoral head between the two groups was not significant ( P=0.488). Compared to sole FNS internal fixation treatment, Ti-Robot assisted FNS internal fixation for elderly Garden typeⅡ and Ⅲ femoral neck fractures can reduce incision time, achieve minimally invasive and accurate nail implantation, and decrease intraoperative fluoroscopy frequency, leading to improved postoperative hip joint function recovery.

Factors associated with early failure of the femoral neck system (FNS) in patients with femoral neck fractures

BackgroundFemoral neck system (FNS) is a new type of internal fixation system which has been widely used for treating femoral neck fractures (FNFs).Compared with other internal fixation methods, FNS is minimally invasive and stable, and often achieves satisfactory short-term efficacy.Early failure of FNS (EFFNS) is not uncommon, however, there are few literatures and reports on factors associated with EFFNS.This study aimed to survey the prevalence and risk factors of EFFNS.MethodsWe retrospectively analysed 62 patients with FNFs and underwent FNS fixation between 2019 and 2021. Demographic data, clinical characteristics, radiographic features and treatment process were described. Multifactor logistic regression analysis was used to analyse the different influencing factors.ResultsOut of the 62 FNFs patients, 10 patients (16.1%) developed EFFNS, including 6 cases of severe femoral neck shortening, 2 cases of screw-out, 1 case of avascular necrosis of the femoral head and 1 case of nonunion. In the failure group, all patients were younger than 65 years old, which was significantly higher than 59.6% in the healing group (P = 0.012). There were no significant differences in sex(P = 0.490), BMI (P = 0.709), injured side (P = 0.312), injury mechanism (P = 0.617), reduction method(P = 0.570),femoral neck-shaft angle(P = 0.545), Pauwels classification (P = 0.564) and Garden classification (P = 0.195). Moreover, we not found that Garden classification (P = 0.464) and age (P = 0.128) were statistically significant risk factors for EFFNS at multivariate analysis.ConclusionIn this study, sex, BMI, injury side, injury mechanism, reduction method, Pauwels angle, femoral neck-shift angle, Pauwels classification and Garden classification were excluded as EFFNS risk factors. Moreover, our study demonstrated that age and Garden classification were not significant risk factors at multivariate analysis.Trial registrationChiCTR, ChiCTR2100051360. Registered on 21 September, 2021. https://www.chictr.org.cn/index.aspx.

Surgical management of neck of femur fractures in patients younger than sixty-five years: a comparative study of three fixation methods.

Several surgical implants have been used for the treatment of neck of femur fracture (NOF) in younger patients such as dynamic hip screw (DHS) and cannulated compression screw. However, the superiority of one or another osteosynthesis device remains a matter of debate. The aim of this work is to evaluate and compare three fixation modalities: Cannulated Hip Screws (CHS), DHS and DHS associated to anti-rotating screw for surgical treatment of femoral neck fracture in young adults. It is a retrospective comparative study of three series of NOF fractures treated surgically over a period of ten years; including young adult patients (age > 18 years and < 65 years) treated conservatively using closed or open reduction and internal fixation. All types of NOF fractures according to Garden classification were included. Pathological, basi-cervical fractures and fractures on previously operated hips were excluded. The minimum follow-up recommended was two years. Clinical evaluation was based on the Postel Merle d'Aubigné score (PMA), the visual analogue scale (VAS), the Parker score, and the Hip Disability and Osteoarthritis Outcome Score (HOOS score). Reduction quality was assessed on X-rays. Our series included 72 patients that were divided in three groups: Group A: Fixation using cannulated hip screws (33 patients). Group B: Fixation using DHS only (21 patients). Group C: Fixation using DHS associated to anti-rotation screw (18 patients). The patients of group A had better PMA and VAS scores, but there was no statistically significant difference. However, a significant difference (p=0.001) was found for the HOOS score. The fractures treated with DHS associated with anti-rotating screws, had the highest loss of reduction in the vertical axis (Yp) with the highest femoral head collapse (Zp) values. Group A had the lowest loss of reduction in the horizontal axis (Xp). There was no significant difference between the three methods of osteosynthesis in terms of loss of correction though. We found comparable results in terms of healing and complication rates and loss of reduction for the three groups with no significant difference. However, the HOOS score was significantly better in the cannulated hip screw group.

Study on effectiveness of treating femoral neck fractures based on theory of "positive support"

To explore effectiveness of positive support reduction and internal fixation in the treatment of femoral neck fractures. A clinical data of 74 patients with femoral neck fractures treated with hollow screw internal fixation between September 2017 and September 2021 was retrospectively analyzed. Based on the quality of fracture reduction, they were divided into positive support reduction group (group A, n=25), negative support reduction group (group B, n=21), and anatomical reduction group (group C, n=28). There was no significant difference in baseline data such as gender, age, cause of injury, disease duration, fracture side, Garden classification, and fracture line position classification between groups (P>0.05). The occurrence of complications such as early fixation failure, femoral neck shortening, non-union of fractures, and femoral head necrosis in three groups, as well as the Harris score of the hip joint were recorded and compared. All patients had primary healing of incisions after operation and were followed up more than 12 months. The follow-up time for groups A, B, and C was (21.1±5.7), (22.6±4.3), and (21.9±4.1) months, respectively; there was no significant difference between groups (P>0.05). There was no significant difference in the incidences of non-union of fractures, early internal fixation failure, and the femoral head necrosis between groups (P>0.05). The incidence and length of femoral neck shortening, and the hip Harris score at last follow-up in groups A and C were all superior to those in the group B, with significant difference (P<0.05). There was no significant difference in the above indicators between groups A and C (P>0.05). Positive support reduction can provide a good biomechanical environment for the healing of femoral neck fractures, thereby achieving a higher fracture healing rate, reducing the occurrence of femoral neck shortening, minimizing the function of hip joint, and achieving effectiveness similar to anatomical reduction.

Complications and Outcomes of the Internal Fixation of Non-displaced Femoral Neck Fracture in Old Patients: A Two-Year Follow-Up.

Background Fractures of the proximal femur are amongst the most common injuries in the elderly population. While there is a clear consensus regarding the management of displaced femoral neck fractures, the management of non-displaced fractures is less clear. Both fixation and arthroplasty are valid treatment options. Internal fixation is a less invasive procedure, but it carries the risks of non-union and avascular necrosis (AVN) of the femoral head. The literature describes varying complication rates associated with these risks. We aim to describe a series of elderly patients above the age of 65 years with non-displaced fractures of the femoral neck who were treated with internal fixation. Our objectives are to determine the union rate and complications in this group and to elucidate the factors that influence these outcomes. Methods We conducted a retrospective review of all patients aged 65 years and older who presented with femoral neck fractures at our level 1 trauma unit between 2018 and 2020. Fractures were classified using the Garden classification system, and only those with Garden 1 or 2 fractures (non-displaced) were included. Preoperative radiographs or intraoperative fluoroscopy images were used to classify fractures using the Pauwels classification. Serial postoperative radiographs and clinical notes (up to 24 months postoperatively) were reviewed to assess the union rate and the development of complications. Both non-union and AVN were analysed for their associations with age, sex, Pauwels grade and comorbidities. A subgroup analysis of the complications was performed to elucidate their association with age groups (<80 and >80 years) and types of fixations (dynamic hip screws {DHS} and cannulated screws). Results A total of 148 patients, consisting of 60 males and 88 females, were included in the analysis. The patients had a mean age of 78.5 years (ranging from 65 to 98 years). The union rate without any degree of AVN was 90.7%, with six non-unions (4.05%) and six patients experiencing AVN (4.05%). No difference in outcome was detected between the two groups based on age. High (type 2 or 3) Pauwels grade (p = 0.05) and treatment with cannulated screws (p = 0.02) were indicated as significant factors for non-union. All patients who developed AVN were noted to have a comorbidity that is known to predispose them to AVN. Conclusion Our series shows a union rate of 90.7%, which is comparable to the union rates reported in other published literature. Our results suggest that age does not independently influence the outcome of fixation for these fractures. We conclude that fractures with vertical orientation (Pauwels grade 2 or 3), when treated with cannulated screws, are more likely to result in non-union. AVN is the second most common complication after non-union, which is also associated with other risk factors for AVN.

Treatment of femoral neck fractures with closed reduction assisted by joystick technique and cannulated screw fixation

To investigate the effectiveness of joystick technique assisted closed reduction and cannulated screw fixation in the treatment of femoral neck fracture. Seventy-four patients with fresh femoral neck fractures who met the selection criteria between April 2017 and December 2018 were selected and divided into observation group (36 cases with closed reduction assisted by joystick technique) and control group (38 cases with closed manual reduction). There was no significant difference in gender, age, fracture side, cause of injury, Garden classification, Pauwels classification, time from injury to operation, and complications (except for hypertension) between the two groups ( P>0.05). The operation time, intraoperative infusion volume, complications, and femoral neck shortening were recorded and compared between the two groups. Garden reduction index was used to evaluate the effect of fracture reduction, and score of fracture reduction (SFR) was designed and was used to evaluate the subtle reduction effect of joystick technique. The operation was successfully completed in both groups. There was no significant difference in operation time and intraoperative infusion volume between the two groups ( P>0.05). All patients were followed up 17-38 months, with an average of 27.7 months. Two patients in the observation group received joint replacement due to failure of internal fixation during the follow-up, and the other patients had fracture healing. Within 1 week after operation, the Garden reduxtion index of the observation group was better than the control group; the SFR score of the observation group was also higher than that of the control group; the proportion of femoral neck shortening within 1 week after operation and at 1 year after operation in the observation group were lower than those in the control group. The differences of the above indexes between the two groups were significant ( P<0.05). The joystick technique can improve the effectiveness of closed reduction of femoral neck fractures and reduce the incidence of femoral neck shortening. The designed SFR score can directly and objectively evaluate the reduction effect of femoral neck fracture.

Radiological analysis of coronal angulation of femoral neck fracture

ObjectiveCurrently, the surgical treatment of femoral neck fracture is mainly artificial joint replacement and internal fixation. In clinical work, the author found that intraoperative and postoperative X-ray verification of anatomical fracture reduction and proper position of internal fixation in clinical cases of internal fixation surgery. However, through follow-up, unknown shortening of the femoral neck was found. Therefore, the concept and classification of femoral neck coronal angulation and related factors are proposed and verified. MethodsIn the first part, 82 patients with femoral neck fractures treated by internal fixation in our hospital from January 2016 to January 2021 were retrospectively analyzed by deep learning. In the second part, the correlation between the coronal angulation and femoral neck shortening distance, Pauwels angle, and age were analyzed by statistical method. ResultsIn the first part, through the average analysis of four groups of different coronal angulations, it was found that the shortening distance increased first and then decreased with the increase of coronal angulations. In the second part, it was found that there were significant differences among the data groups of shortening distance, coronal angulation, and Pauwels angle (P < 0.05). According to the scatter diagram of coronal angulation and Garden classification, there was no significant correlation between coronal angulation and Garden classification. The mean value of the coronal angulation when age <60 was much earlier than when age ≥60, but there was no statistical significance (P = 0.622 > 0.05). ConclusionFemoral neck coronal angulation is verified, and the coronal angulation is correlated with the shortening distance and Pauwels angle.