Garden Classification Research Articles

Accuracy of valgus osteotomy using dynamic hip screw

BackgroundNon-union of neck femur is a common but difficult situation to manage especially in young adults. There are two main options of arthroplasty or osteotomy. The aim of this study was to assess the results of intertrochanteric valgus osteotomy in non-union femoral neck fractures. Patients and MethodsWe present a study of 44 cases of neck femur non-union including untreated fractures, late presentations (more than 3 weeks), treated with compression screw, DHS. From 2006-2016, 44 patients presented to our institute and we analyzed them prospectively on the following criteria: Pauwel’s angle, Garden classification, union at fracture site, union at osteotomy site, osteoporosis and AVN changes. Inclusion criteria were age<65, neck not reabsorbed, no AVN. Powel’s angle was calculated using the anatomic axis of femur. Wedge angle is equal to Powel’s angle minus 30 degree. Entry point of DHS was at the base of greater trochanter and tip of the screw was in the inferior quadrant. Y osteotomy was done in the distal half of the lesser trochanter with a proximal straight cut. ResultsComplete union was noted in 93% of the cases. One patient with uncontrolled diabetes developed severe infection and was treated with excision arthoplasty. AVN occurred in 3 cases. The Powell’s angle was reduced to mean 30 (22–39). The neck shaft angle was increased to mean 140 (130–150). Limp was noted in almost all patients but they were able to walk full weight bearing with or without the support of a stick. ConclusionValgus intertrochanteric osteotomy achieved good union rates and good functional outcome with minimal complications.

Non-parallel screw fixation for femoral neck fractures in young adults.

Current literature shows divergence of views regarding screws positioning in femoral neck fractures fixation. The goal of this study is to evaluate the efficiency of divergent screw fixation for fracture neck of femur (NOF). The study was conducted at an academic Level 1 Trauma Center. This is a retrospective study conducted from October 2013 to October 2016. The study included 41 patients (33 males, 8 females) suffering from fracture NOF who were fixed using BDSF technique (26 within 24h. & 15 after 24h.). The average age was 41.5 y (23-49 y). According to Garden classification; 17 patients (41.5%) were type 4, 24 patients (58.5%) were type 3. According to Pauwel's classification; 8 cases (19.5%) were type III, 25 cases (61%) were type II & 8 cases (19.5%) were Type I. Thirty-six cases (88%) were trans-cervical, 4 Sub-capital (9.5%) and 1 (2.5%) Basi-cervical. Six patients had comminution at the fracture site. We evaluated radiographic outcomes of union, femoral neck shortening, screws back-out & femoral head avascular necrosis (AVN). We also evaluated functional outcome using the Harris hip score. Follow-up was 24 months on average (ranging from 20 to 29 months). One patient was lost during the follow up, the remaining 40 cases gave the following results regarding union: 38 united (within 3-4 months), 2 patients were un-united & one of them developed AVN. Twenty-seven patients (71%) had femoral neck shortening <5mm, 8 patients (21%) had shortening 5-10 & 3 patients (8%) had shortening >10mm. Shortening was on average 3mm (0-15). Screws back-out distance was on average 4mm (0 to16). Patients with mild femoral neck shortening had Harris hip score of 96 on average (92-100), those with moderate shortening had a score of 75 on average (72-79), those with severe shortening had a score of 62 on average (56-68). The Authors believes this method provides better union rate & less incidence of femoral neck shortening than that of the conventional inverted triangle screws configuration reported in literature. However multi-center studies & long term follow-up is needed to fully evaluate this method.

Fracture neck of femur treated with hemiarthroplasty and cannulated cancellous screw fixation: a comparative study

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Intracapsular fracture neck of femur has always presented great challenges to every Orthopaedic surgeons and it is remain a mystery whether to fix or to replace the fracture in the elderly. The aim of the study was to analyze the functional outcome of two widely used and accepted modalities of treatment in the age group 57-75 years, in Garden’s type I and II fractures, namely (a) cannulated cancellous screw fixation(internal fixation) and (b) modular bipolar prosthetic replacement of the femoral head (hemiarthroplasty).&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; The total 110 patients were including in the study from age groups 57-75 (mean age 66). The Garden classification of fracture neck of femur was used to evaluate the displacement of femoral neck fractures. Only grade 1 and 2 was included in the study. 55 patients were included in each group A and B. Osteosynthesis (fracture fixation) was carried out by closed reduction and insertion of cannulated cancellous screw and in other group hemiarthroplasty was done.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; In group A 55 patient with fracture neck of femur was treated by osteosynthesis i.e. fixation using 02 or 03 cannulated cancellous screw and in group B, 55 patients with fracture neck of femur was treated by modular bipolar replacement hemiarthroplasty. In Group A out of 55, 41 patients union was achieved between 08 to 14 months (mean 11.5 month), 09 patients developed non-union even after 16 months and 05 patients develop collapse of head with AVN with shortening at end of 02 year, however in Group B out of 55 patients 51 patients started walking after 2&lt;sup&gt;nd&lt;/sup&gt; postoperative days, 02 patients developed infection, and 02 patients developed posterior dislocation.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; The fracture fixation may be tempting for fracture neck femur in age group 57-75 especially of Garden Type I but internal fixation put risk of non-union and AVN and second surgery may be required after few months or years if patients survive. Based on results in our study we therefore can conclude that in Garden Type I and II femur neck fractures in the patients between 57-75 years of age, hemiarthroplasty is the better modality of treatment.&lt;/p&gt;

Bi-planar robot navigation for cannulated screw fixation in the treatment of femoral neck fractures

Objective To investigate the clinical results of Bi-plane robot navigation for cannulated screw fixation in the treatment of femoral neck fractures. Methods Between May 2011 and May 2015, 86 patients with femoral neck fracture who were fixed with cannulated screws were retrospectively analyzed. The patients were divided into navigation group and non-navigation group according to whether the Bi-planar robot used for navigation or not. The patients were matched concerning gender, age and Garden classification. A total of 64 patients were included in the study. In navigation group, there were 32 cases, including 10 males and 22 females. The average age was 59.4±5.6 yr (range, 51-68 yr). According to Garden classification, there were 1 case of type I, 7 cases of type II, 14 cases of type III and 10 cases of type IV. In non-navigation group, there were 32 cases, including 12 males and 20 females. The average age was 59.1±4.9 yr (range, 53-70 yr). According to Garden classification, there were 1 case of type I, 5 cases of type II, 18 cases of type III and 8 cases of type IV. Sixty-four cases were all fixed with cannulated screws. The fluoroscopy time, fluoroscopy times, drilling times, times of cannulated screw replacement, cannulated screw insertion time, blood loss, relative position between any two cannulated screws in postoperative AP view and lateral view, the angle between each cannulated screw and the femoral neck axis, fracture healing time and functional score were recorded. Results The parameters in navigation group versus non-navigation group were as follows: the average fluoroscopy time was 10.1±2.9 s vs 36.8±7.5 s, the average fluoroscopy times was 11.4±3.2 vs 43.9±11.0, the average drilling times was 3.9±1.1 vs 18.5±3.2, the average times of cannulated screw replacement was 0.4±0.6 vs 1.0±0.7; the average blood loss was 29.4±14.7 ml vs 50.2±17.1 ml, cannulated screws placement time averaged 28.8±7.3 min vs 43.8±7.9 min. The angle between any of two cannulated screws averaged 3.1°±1.1° vs 7.3°±1.2° in AP view and 2.9°±1.0° vs 4.4°±2.3° in lateral view, the angle between the cannulated screw and the femoral neck axis averaged 4.4°±1.6° vs 7.5°±1.7° in AP view and 4.9°±1.6° vs 8.0°±1.3° in lateral view. Significant differences were found concerning all above parameters between the two groups. Conclusion Bi-plane robot navigation technique helps more accurate cannulated screw fixation in the treatment of femoral neck fracture. This technique is less invasive. It decreases the time of screw insertion and reduces the radiation exposure. Key words: Robotics; Surgery, computer-assisted; Femoral neck fractures; Internal fixators

Ipsilateral proximal and shaft femoral fractures

PurposeTo study the management and evaluate anatomical and functional outcomes of patients with ipsilateral proximal and shaft femoral fractures. MethodsA retrospective, descriptive and analytic study lasted for ten years and a half ranging from January 1, 2005 to June 30, 2015. The following parameters were studied: epidemiology, fracture characteristics, therapeutic, anatomical and functional outcomes. The correlation between different parameters was analyzed with Fischer test. The significant threshold was defined for p value <0.05. ResultsTen medical files were registered. There were 7 men and 3 women, with a sex ratio of 2.33. The average age was 46 years (range: 29–62 years). It was about traffic road accidents in all cases. Motorcycle–motorcycle and motorcycle–car collision were most frequent. Average admission delay was 7 h (range: 1.5–24 h). Left side was most reached in 8 cases. According to Garden classification, there was type III cervical fracture in 2 cases, type II in 1 case and type IV in 1 case. According to Ender classification, there was type I trochanteric fracture in 3 cases, type VI in 2 cases and type VII in 1 case. According to AO classification, there was type A shaft fracture in 6 cases (A2 in 4 cases and A3 in 2 cases), type B in 2 cases (B1 in 1 case and B2 in 1 case) and type C in 2 cases (C1 in 1 case and C2 in 1 case). Average surgical delay was 28.7 days (range: 11–61 days). For proximal femoral fracture, Moore prosthesis was used in 1 case, blade plate 130° in 2 cases, long Gamma nail in 4 cases, double screwing in 2 cases and dynamic hip screw in 1 case. For shaft femoral fracture, blade plate 95° was used in 3 cases, low compressive plate in 2 cases. Osseous contention was achieved in 4 cases with long Gamma nail and in 1 case with long blade plate 130°. Nonunion of cervical fracture was achieved in 2 cases. The average osseous healing delay was 5.14 months (range: 3–12 months) for proximal femoral fracture and 5 months (range: 3–8 months) for shaft femoral fractures. According to Friedman and Wyman criteria, functional results were good in 4 cases, average in 4 cases and bad in 2 cases. Regarding implants, healing delay showed no statistic difference between one-implant group and two-implant group (p = 0.52), and among the patients with different functional outcomes (p = 0.52). Functional outcomes showed no statistic difference between one-implant group and two-implant group (p = 0.46). ConclusionIpsilateral proximal and shaft femoral fractures are relatively uncommon in our daily activities. It is difficult to recognize proximal femoral fractures which are unnoticed. Results are generally good if the doctors take the two fractures into account in the management.

Treatment of displaced femoral neck fractures in young patients with DHS and its association to osteonecrosis

ObjectiveThe purpose of this study is to evaluate the performance of dynamic hip screw for the treatment of dislocated femoral neck fractures in young patients, focusing on osteonecrosis. MethodsA series of 53 patients with less than 55 years of age were retrospectively evaluated. All patients had dislocated femoral neck fractures (Garden III or IV) and were treated with DHS. Ficat's staging system was used to evaluate avascular necrosis. ResultsThere were 38 (71.7%) males and 15 (28.3%) females, with an overall mean age at the onset of fracture of 41.9 years (±12.8). According to Garden's classification, 21 (39.6%) fractures were classified as type III and 32 (60.4%) were considered totally dislocated, Garden IV. Fracture healing was achieved in 39 patients (73.6%). Thirteen cases of avascular necrosis were observed (24.6%). ConclusionsThe incidence of avascular necrosis in young patients with a displaced femoral neck fractures treated with DHS was 24.6%. No statistically significant association was found between times elapsed to surgery, fracture displacement, and presence of derotation screw with osteonecrosis. Level of evidence IV.

Is surgeons' experience important on intra- and inter-observer reliability of classifications used for adult femoral neck fracture?

PurposeTo evaluate whether surgeons' experience affect inter- and intra-observer reliability among mostly used classification systems for femoral neck fractures. Material and methodsA power point presentation was prepared with 107 slides which were antero-posterior radiographs of each femoral neck fracture. Five residents, 5 orthopaedic surgeons and 5 senior orthopaedic surgeons reviewed this presentation and classified the fractures according to Garden, Pauwels and AO classifications. The order of the slides was changed and reviews were repeated after 3 months. Fleiss kappa and intraclass correlation coefficient values were calculated to evaluate inter and intra-observer reliability. ResultsGarden and AO classifications' inter-observer reliabilities were similar and higher than Pauwels classification. Among three experience groups, the inter-observer reliability for Garden classification was highest in senior surgeon group, the interobserver reliability for AO classification was highest in surgeon group, and interobserver reliability of Pauwels classification was highest in low experienced groups (residents and surgeons). Intra-observer reliability was highest for Garden and lowest for Pauwels classifications. Surgical experience was found to be not effective for intraobserver reliability. ConclusionBoth Garden and AO classifications were more reliable than Pauwels classification. Surgical experience was not significantly important on these three classification systems' evaluation.Level of Evidence: Level IV, Diagnostic study

Early curative effects and influencing factors of primary total hip replacement for senile femoral neck fractures

Objective To investigate the early curative effects and influencing factors of primary total hip replacement for senile femoral neck fractures. Methods Between January 2013 and May 2015, 116 elderly patients with femoral neck fracture underwent primary total hip replacement. They were 34 males and 82 females, with an average age of 70.2 years. By the Garden classification, we had 23 cases of type Ⅰ, 34 cases of type Ⅱ, 38 cases of type Ⅲ, and 21 cases of type Ⅳ. Their clinical data were statistically analyzed, including gender, age, body mass index (BMI), preoperative concomitant diseases, Garden classification, injury causes, operative indexes, postoperative rehabilitation time, and postoperative complications. Single factor analyses were conducted to find out the relative factors using χ2 test before multiple factors analyses using logistic regression to screen the significant factors influencing hip functional recovery. Results The 116 patients obtained follow-ups for 12 to 23 months (mean, 18.3 months). According to the Harris hip scores for hip function at the last follow-up evaluation, 36 cases were excellent, 52 good, 20 fair, and 8 poor, giving a good to excellent rate of 75.9%. Single factor analyses found that age, BMI, operation time, surgical approach, discrepancy in bilateral lower limb lengths, postoperative analgesia, total blood loss, postoperative rehabilitation time, and postoperative complications were significantly related to hip functional recovery (P<0.05). Logistic regression analyses found that BMI, surgical approach, discrepancy in bilateral lower limb lengths, postoperative analgesia, total blood loss, and postoperative rehabilitation time were the main factors influencing hip function recovery (P<0.05). Conclusions Primary total hip replacement may lead to fine early curative effects for elderly patients with femoral neck fracture. Smaller BMI, minimally invasive approach, less discrepancy in bilateral lower limb lengths, post-operative analgesia, less total blood loss, and longer postoperative rehabilitation time may facilitate hip function recovery. Key words: Femoral neck fractures; Arthroplasty, replacement, hip; Factor analysis, statistical; Elderly

Treatment of displaced femoral neck fractures with percutaneous compression plate in young and middle-aged patients

Objective To explore the operative treatment of displaced femoral neck fractures with percutaneous compression plate (PCCP) in young and middle-aged patients. Methods Forty-three young and middle-aged patients with displaced femoral neck fracture were treated with PCCP from May 2011 to May 2015. They were 24 males and 19 females, aged from 21 to 55 years (mean, 38.2 years). According to the Garden classification, 29 cases were type Ⅲ and 14 type Ⅳ. According to the Pauwels classification, 18 cases were type Ⅱ and 25 type Ⅲ. After reduction was conducted manually or using percutaneous joystick technique, nailing was carried out under the guidance of the three-dimensional position sticker which had been invented by ourselves for minimally invasive treatment of hip fractures. Clinical and radiographic outcomes were recorded after operation and postoperative hip function was evaluated using Harris score. Results Manual reduction succeeded in 38 cases and the other 5 cases experienced reduction by percutaneous joystick technique after failure of manual reduction. For this series, the operation time ranged from 35 to 60 minutes (mean, 53.2 minutes), explicit blood loss from 20 to 80 mL (mean, 65.3 mL), frequency of X-ray exposure from 6 to 20 times (mean, 11.8 times) during operation, the partial weight-bearing time from 14 to 30 days (mean, 22.5 days), and the full weight-bearing time from 2.5 to 4.0 months (mean, 3.2 months). The 43 cases were followed up for 12 to 46 months (mean, 28.5 months). Bone union was achieved in all after 3 to 7 months (mean, 4.3 months). The Harris hip scores at the final follow-ups ranged from 71 to 98 points (mean, 92.7 points). The excellent to good rate was 95.3%, with 26 excellent cases, 15 good ones and 2 fair ones. Two cases developed femoral avascular necrosis. No nonunion, implant failure or hip varus was observed during follow-ups. Conclusion Although it is difficult to treat displaced femoral neck fractures in young and middle-aged patients using PCCP, the surgery can be simplified with the aid of certain surgical techniques so that the advantages of PCCP can be realized, like minimal invasion, rigid fixation, low risk of complications and satisfactory therapeutic effect. Key words: Femoral neck fractures; Fracture fixation, internal; Bone plates; Surgical technique

Ultrasound guided K-wire reduction of irreducible femoral neck fractures

Objective To evaluate the effect of ultrasound-guided K-wire reduction of irreducible femoral neck fractures. Methods A retrospective analysis was made on 21 patients with irreducible femoral neck fractures hospitalized from January 2011 to January 2014. There were 13 males and 8 females, aged 23-60 years (mean, 41.5 years). The fractures of nine patients were caused by road traffic accidents, seven by slipping, and five by fall from the height. According to the Garden classification, four patients were classified as type Ⅱ, eleven type Ⅲ, and six type Ⅳ. Patients were placed in traction bed for limb traction. After 3-times unsuccessful reduction with limb traction, the patients were performed ultrasound-guided localization of superficial femoral artery, vein and nerve in the hip, marked and stabilized with two K-wires into the surface markers. Position relations of femoral artery, vein and nerve with the femoral head were determined under fluoroscopic guidance. After operation, the part with K-wire insertion was routinely reviewed by ultrasound, the anterior and lateral positions of the hip joint were routinely reviewed, and the sensorimotor function of the area of femoral nerve and sense function of the anterolateral femoral cutaneous nerve were routinely examined. Quality of reduction was assessed with the Garden index. Hip function was assessed with Harris score. Results All patients were followed up for mean 18 months (range, 6-28 months), which showed satisfactory reduction. No major vascular or nerve injury occurred intraoperatively. Postoperative ultrasound examination revealed no local hematoma formation, normal functions of the femoral nerve and normal superficial sensibility of the anterolateral femoral cutaneous nerve. No deep vein thrombosis of the lower limb occurred postoperatively. According to the Garden index, reduction was reached grade Ⅰ in fourteen patients and grade Ⅱ in seven patients. Harris hip score was excellent in 14 patients, good in six and poor in one, with the excellent-good rate of 95%. One patient underwent total hip arthroplasty for the postoperative femoral head necrosis, and none had screw displacement and implant loosening. Conclusion Ultrasound guided K-wire reduction of irreducible femoral neck fractures is associated with simple equipment, high repeatability, safe and effective results, and decreased iatrogenic injury. Key words: Ultrasonography; Femoral neck fractures; Reduction

The Correlation between the Fracture Types and the Complications after Internal Fixation of the Femoral Neck Fractures.

PurposeThis study aims to determine the correlation between the fracture patterns and the complications in patients with femoral neck fracture treated with internal fixation.Materials and MethodsThe study comprises 45 patients with femoral neck fracture treated with multiple screws or compression hip screw between May 2008 and April 2012. The mean age was 48 years at the time of the surgery and the mean duration from initial injury to surgery was 20 hours. The fracture patterns were identified according to the anatomical location, the Garden classification and the Pauwels classification. The occurrence of nonunion and avascular necrosis were reviewed with clinical results including Harris hip score and Lunceford hip function test. The correlation between the fracture pattern and occurrence of complications were analyzed.ResultsFracture site union was achieved in 40 hips with the average union time of 17 weeks. Five nonunions occurred which showed high likelihood to occur in subcapital type, displaced (Garden stage III or IV) and Pauwels type III fractures (P<0.05). Avascular necrosis was developed in 10 hips which was mostly in subcapital type and Pauwels type III fracture but no statistical significance was found (P>0.05). The mean Harris hip score was 91 points, and Lunceford functional results were excellent in 15 hips, good in 24, fair in 4 and poor in 2.ConclusionThere was high risk of nonunion in subcapital type fracture, displaced fracture (Garden stage III and IV) and vertically oriented fracture (Pauwels type III). Careful attention is needed in these fracture types.

Preoperative three-dimensional reconstruction for displacement assessment of femoral neck fracture and its clinical significance

Objective To measure the displacement in femoral neck fracture by three-dimensional reconstruction, reconsider the classic Garden classification and provide guidance to evaluate the severity of different types of fracture and prognosis. Methods One hundred and fifty patients with femoral neck fracture admitted between May 2012 and August 2014 were included including 23 Garden typeⅠfracture, 30 type Ⅱ fracture, 42 type Ⅲ fracture and 55 type Ⅳ fracture. Bilateral proximal femurs in all were scanned by spiral CT preoperatively. Mimics 10.01 software was used to develop the three-dimensional model by thresholding, region growing and mirror matching. Displacement of the femoral head was measured with the three-dimensional design. Results Among the six patients with incomplete Garden type Ⅰ fracture, three were verified as incomplete fracture and three complete fracture using the three-dimensional measurement technology. Femoral head displacement angle was (19.8±12.5)° in impacted femoral neck fracture. In the patients with type Ⅱ, Ⅲ and Ⅳ fractures, the medial displacement of the femoral head was (7.0±2.5)mm, (14.1±6.8)mm and (20.4±9.3)mm, the deepest point of fovea capitis was (11.6±4.4)mm, (23.2±11.2)mm and (30.1±10.1)mm; the femoral head displacement angle was (22.1±9.9)°, (31.5±15.2)° and (37.8±13. 5)°. Differences in dimensional displacement parameters among all types fractures were statistically significant except the comparison between type Ⅱ fracture and impacted fracture (P<0.05). Conclusions Classic Garden classification has some limitations, thus clinicians should reunderstand the femoral neck fracture and formulate more reasonable treatment protocols. Three-dimensional reconstruction provides accurate evaluation of fracture type and displacement parameters and has high clinical value. Key words: Femoral neck fractures; Imaging, three-dimensional; Displacement

Association between spatial displacements of femoral neck fracture and avascular necrosis of femoral head after internal fixation

Objective To explore the association between the spatial displacements in the three-dimensional reconstruction of femoral neck fracture and avascular necrosis of femoral head after internal fixation. Methods One hundred and sixty-three patients with femoral neck fracture were included in this study who had been treated at our institute between January 2010 and January 2013. They were 61 males and 102 females, with an average age of 55.7 years. By Garden classification, 20 cases were type Ⅰ, 30 type Ⅱ, 57 type Ⅲ and 56 type Ⅳ. All their preoperative and postoperative primitive CT data were imported to Mimics 10.01 software for three-dimensional reconstruction of femoral neck fractures in which the spatial displacement parameters (the lowest displacement at the dimple, central displacement, and spatial displacement angle) were measured. The patients were divided into 2 groups according to presence or absence of postoperative avascular necrosis of femoral head. The 2 groups were compared in terms of demographic data, preoperative and postoperative spatial displacement parameters. Multivariate logistic regression analysis was performed to explore the risk factors of avascular necrosis of femoral head. Results The average duration of follow-up was 3.1 years (range, from 2.5 to 5.4 years) . Avascular necrosis of femoral head was found in 33 cases (20.2%) . There were significant differences between the necrosis and necrosis-free groups in preoperative Garden classifications, all the preoperative and postoperative spatial displacement parameters (the lowest displacement at the dimple, central displacement, and spatial displacement angle) (P<0.05) . Multivariate logistic regression analysis showed that preoperative spatial displacement parameters of the femoral head, preoperative Garden classification of the fracture, and postoperative spatial displacement parameters of the femoral head were associated with avascular necrosis of femoral head (P<0.05). Conclusions Three-dimensional reconstruction of femoral neck fracture can accurately assess preoperative displacements and postoperative reduction. Preoperative displacement of the femoral head, fracture classification and postoperative reduction are the major risk factors for incidence of femoral head necrosis. Key words: Femoral neck fractures; Imaging, three-dimensional; Photogrammetry; Femur head necrosis

Outcome Analysis of Hemiarthroplasty vs. Total Hip Replacement in Displaced Femoral Neck Fractures in the Elderly.

Management of displaced fracture neck femur in the elderly population is frequently done by Hemiarthroplasty or Total Hip Replacement (THR). It avoids high rates of nonunion and avascular necrosis which usually occur after internal fixation of neck femur fractures in this age group. The present study aimed to evaluate patient function and complications following hemiarthroplasty and total hip replacement in elderly population with displaced femoral neck fractures. Patients above 60 years of age with displaced fracture neck femur were studied over the period of four years. All the clinical parameters and co-morbid conditions were noted at the time of presentation. The patients associated with co-morbid conditions and underlying pathology were excluded from study. Garden's classification was used for classification of neck femur fractures. After due informed consent patients of displaced fracture neck femur were randomized by simple randomization and allocated for hemiarthroplasty or THR. Antibiotics were given preoperatively at the time of induction and postoperatively for 5-7 days. Surgery was carried out by Modified Gibson approach. Any complications during pre and postoperative period were noted. Follow-up of patients was done 1 month, 3 months, 6 months and 1 year interval with the help of Harris hip score. Total 80 patients were enrolled in the study group, with 40 patients in each group. The mean age of patients was 73 years in hemiarthroplasty group and 78 years in THR group. Female to male ratio was 55:45. Mean operative time was 35 minutes in hemiarthroplasty group and 45 minutes in THR. Average intraoperative blood loss was 200cc and 300cc in hemiarthroplasty and THR respectively. The mean hospital stay was 14 days in both the groups. Superficial wound infection was noted in hemiarthroplasty group while in THR group deep wound infection (n=1) and prolonged ICU stay (n=1) were noted. The mean Harris hip score was better in THR group as compared to Hemiarthroplasty group at one year follow-up. In elderly patients with fracture neck femur hemiarthroplasty takes less operative time, less blood loss per operatively and few complications postoperatively as compared to THR. The functional outcome at one year is better with THR as compared to hemiarthroplasty.

Metformin Prevents Nonunion after Three-Cannulated-Screw Fixation in Displaced Femoral Neck Fractures: A Retrospective Study.

Patients aged from 40 to 60 with displaced fractures of the femoral neck (Garden III or IV) who received fixation with three cannulated screws from January 2005 to December 2012 were evaluated retrospectively for the development of nonunion. Plasma HbA1C, a marker for long-term plasma glucose level, anti-T2DM medication, and other potential risk factors were recorded for the purpose of this study. There were no differences between the union and nonunion groups with respect to age, gender, Garden classification, Pauwel's angle, reduction quality, and T2DM presence. There were significant differences in reduction quality and preoperative plasma HbA1C level between patients with and those without union. The odds ratio (OR) for fracture nonunion was 2.659 (95% confidence interval [CI], 1.530–4.620) in subjects with anatomical reduction compared with those without anatomical reduction, 4.797 (95% CI, 1.371–16.778), in subjects with poor blood glucose control (HbA1C > 10%). The metformin usage showed a preventive effect on nonunion development (OR: 0.193 and CI: 0.060–0.616). The nonunion rate of metformin group (6.7%, 6/89) was even much lower than that of patients without T2DM (17.4%, 80/460).

Clinical Results of Internal Fixation of Subcapital Femoral Neck Fractures.

BackgroundSubcapital femoral neck is known to cause many complications, such as avascular necrosis (AVN) of the femoral head or nonunion, compared with other femoral neck fractures. The purpose of this study was to analyze the incidence of AVN and fixation failures in patients treated with internal fixation using cannulated screws for the subcapital femoral neck fractures.MethodsThis study targeted a total of 84 cases of subcapital femoral neck fractures that underwent internal fixation using cannulated screws. The average follow-up time after surgery was 36.8 months (range, 24 to 148 months).ResultsNine hips (10.7%) showing AVN of the femoral head and 6 hips (7.1%) showing fixation failures were observed. The factors affecting the incidence of AVN of the femoral head after sustaining fractures correlated well with fracture types in the Garden classification (p = 0.030). The factors affecting fixation failure were the degree of reduction (p = 0.001) measured by the Garden alignment index and firm fixation (p = 0.009) assessed using the technique of 3-point fixation through the inferomedial cortical bone of the femoral neck.ConclusionsThe complication rates for subcapital femoral neck fractures were lower than those previously reported; hence, internal fixation could be a primary treatment option for these fractures.

Femoral neck non-union treatment by valgus intertrochanteric osteotomy.

ABSTRACTOBJECTIVE: The purpose of this study was to evaluate the performance of valgus intertrochanteric osteotomy in femoral neck non-union.METHODS: Forty-two patients with femoral neck fractures with non-union treated using Pauwels' intertrochanteric osteotomy were reviewed. Demographics, time elapsed between fracture and surgery, follow--up, osteosynthesis used, Garden's classification, limb shortening, and x-rays were evaluated. RESULTS: Twenty-two men and 20 women were reviewed. The youngest patient was 18 years old and the oldest 65 years old, with a mean age of 42.4 years (±11.2). The minimum follow-up was 2 years, with a mean of 10.2 years. The average time elapsed between initial fracture and osteotomy was 6.5 months. Twel-ve cases were neglected femoral neck fractures. Nineteen patients were classified as Garden III, and 23 patients as Garden IV. After valgus osteotomy, non-union healing was observed in 38 patients (38/42; 90.4%). Healing of thirty-seven cases of pseudoarthrosis were obtained after the first-attempt osteotomy, and one case required two operations for healing. The osteotomy failed in four cases. Conside-ring the healed osteotomies, good to excellent functional results were achieved in 80.9% (34/42) of the patients. Total hip replacement was subsequently performed in 14.2% (6/42) of the patients for unfavoura-ble outcomes (two for cutting out, two for osteonecrosis, and two for osteoarthritis).CONCLUSIONS: Valgus intertrochanteric osteotomy has a high success rate in archiving healing in femoral neck non-union with good functional results. It is a biological and effective method. Level of Evidence IV, Therapeutic Study.

Assessment of interobserver variation in Garden classification and management of fresh intracapsular femoral neck fracture in adults

ObjectiveTo assess the interobserver agreement on Garden classification of fresh femoral neck fracture and management plan based on anteroposterior (AP) view and also assess if the addition of lateral view changes the classification and management plan. MethodsTen orthopaedic surgeons were asked to classify 35 femoral neck fractures on AP view only and propose the management plan. Then the same films were reshown in conjunction with their lateral view after 10 days. Results were compared with respect to the classification and management plan between two groups. Interobserver agreement was calculated using Fleiss’ kappa. ResultsThere was only a fair interobserver agreement (kappa value 0.39) on Garden classification on AP view only which improved to moderate agreement (kappa value 0.52) after adding a lateral view. While there was only a slight improvement in the interobserver agreement on the management plan on AP view only (kappa value 0.50) and AP combined with lateral views (kappa value 0.52). Supplementation of the lateral view changed the classification in 15.42% of the cases and altered the management plan in 23.14% of the cases. ConclusionWe conclude that lateral view should be obtained routinely on all patients with suspected femoral neck fracture as it definitely has a role in planning treatment of femoral neck fracture.

Effect of dynamic hip screw on the treatment of femoral neck fracture in the elderly

ObjectiveTo discuss the indications, surgical procedures, and curative effect of dynamic hip screw (DHS) in the treatment of femoral neck fracture in the elderly. MethodsA retrospective study was conducted to analyse the clinical data of 42 elderly patients who had been treated for femoral neck fracture with DHS in our department between June 2009 and November 2011. There were 21 males and 21 females with a mean age of 68.5 years (range 60-75 years). According to the Garden Classification, there were 19 cases of type II, 21 cases of type III and 2 cases of type IV fractures. By the Singh Index Classification, there were 3 cases of level 2, 19 cases of level 3 and 20 cases of level 4 fractures. The Harris criterion, complications and function recovery after operation were analysed. ResultsThe average hospitalization time in 42 patients was 11.2 days (range 7-21 days). All patients were followed up for 12-26 months (mean 18 months). No lung infection, deep venous thrombosis or other complications occurred. Partial backing-out of the screws was found in 2 cases. The internal fixation device was withdrawn after fracture healing. Internal fixation cutting was found in 1 case, and he had a good recovery after total hip arthroplasty. The time for fracture healing ranged from 3-6 months (average 4.5 months). According to Harris criterion, 15 cases were rated as excellent, 24 good, 2 fair and 1 poor. The Harris scale was significantly improved from 30.52±2.71 preoperatively to 86.61±2.53 at 6 months postoperatively (P<0.05). ConclusionDHS, being minimal invasive, allowing early activity and weight-bearing, is advisable for treatment of elderly patients with femoral neck fracture. In addition, it can avoid complications seen in artificial joint replacement. It is especially suitable for patients with mild osteoporosis.

Correlation Between Residual Displacement and Osteonecrosis of the Femoral Head Following Cannulated Screw Fixation of Femoral Neck Fractures.

The aim of the study was to introduce a new method for measuring the residual displacement of the femoral head after internal fixation and explore the relationship between residual displacement and osteonecrosis with femoral head, and to evaluate the risk factors associated with osteonecrosis of the femoral head in patients with femoral neck fractures treated by closed reduction and percutaneous cannulated screw fixation.One hundred and fifty patients who sustained intracapsular femoral neck fractures between January 2011 and April 2013 were enrolled in the study. All were treated with closed reduction and percutaneous cannulated screw internal fixation. The residual displacement of the femoral head after surgery was measured by 3-dimensional reconstruction that evaluated the quality of the reduction. Other data that might affect prognosis were also obtained from outpatient follow-up, telephone calls, or case reviews. Multivariate logistic regression analysis was applied to assess the intrinsic relationship between the risk factors and the osteonecrosis of the femoral head.Osteonecrosis of the femoral head occurred in 27 patients (18%). Significant differences were observed regarding the residual displacement of the femoral head and the preoperative Garden classification. Moreover, we found more or less residual displacement of femoral head in all patients with high quality of reduction based on x-ray by the new technique. There was a close relationship between residual displacement and ONFH.There exists limitation to evaluate the quality of reduction by x-ray. Three-dimensional reconstruction and digital measurement, as a new method, is a more accurate method to assess the quality of reduction. Residual displacement of the femoral head and the preoperative Garden classification were risk factors for osteonecrosis of the femoral head. High-quality reduction was necessary to avoid complications.