Intracapsular Femoral Fractures Research Articles

Does the Method of Fixation Affect the Risk of Complications in Patients with Pauwels Type 3, Displaced Intracapsular Femoral Fractures

Background: Patients with Pauwels type III displaced intracapsular femoral fractures (DICFF) are at a high risk of developing avascular necrosis (AVN) and non-union following closed reduction and internal fixation (CRIF). We compared the complications between the Targon femoral neck (TFN) plate and the cannulated cancellous screws (CCS). Methods: This retrospective study reviewed the records of 34 patients younger than 65 years of age who underwent CRIF of Pauwels type III DICFF from January 2007 to January 2018. Patients were evaluated for demographic data as well as the fixation method. Subsequent postoperative radiographs were obtained to assess the incidence of AVN and nonunion. Results: 34 patients were included in the study, of which, 18 (53%) and 16 (47%) were treated using TFN and CCS, respectively There were no significant differences observed between the CCS and TFN cohorts in terms of age (p = 0.90), gender (p = 0.27), time to surgery (p = 0.36), and duration of surgery (p = 0.99). The incidence of AVN and non-union did not significantly differ between the groups, with rates of 38.9% and 43.8%, respectively (p = 0.083) Conclusions: The type of fixation utilized, whether CCS or TFN, did not have a significant impact on the incidence of treatment failure in patients with Pauwels type III fractures treated via CRIF

Multiple cannulated screws for treatment of intracapsular femoral neck fractures in young adult patients: Improved outcomes?

Background: Intracapsular femoral neck fractures (IFNF) in young adult patients generally due to high energy trauma are not uncommon. Traditionally, the preferred treatment method is closed reduction with stable internal fixation as early as possible. However, a complication rate is still hard to be greatly lowered due to unfavorable vascular route anatomically. Purpose: The aim of this retrospective study was to investigate whether a success rate had been improved following far advancement of modern medicine and technology. Methods: For the 3.8-year period, 133 consecutive young adult patients with IFNF due to high energy trauma were treated. Seventy patients (average = 46.5 years) matched for study criteria were enrolled. Closed reduction with multiple cannulated screw fixation for IFNF was performed at an average of 1.0 day after patients arrived at the emergency service. Postoperatively, early ambulation with protected weight bearing was encouraged. Regular follow-up with the interval of 4-6 weeks at the outpatient department (OPD) was scheduled. Results: For an at least 1.5-year (average = 2.4 years) follow-up, 90% (63/70) of IFNF healed at an average of 2.7 months. Osteonecrosis in varied Ficat stages occurred in 21% (15/70) of the femoral head and nonunion occurred in 10% (7/70) of the femoral neck. Complications were treated based on various personal situations. Displaced IFNF had a higher complication rate as compared to non-displaced IFNF (p = 0.03). Satisfactory hip function was achieved in 81% (57/70) of patients. Conclusion: Although fixation devices for IFNF are continuingly designed, complications after treatment are still not greatly decreased. The unfavorable anatomic route of vascularity may be the most important culprit. Any technique which may potentially improve femoral head and neck blood supplies should be continuingly explored.

Weekend Admission of Intracapsular Femoral Neck Fractures Not Associated With a Greater Rate of Mortality or Morbidity.

Introduction:For a number of emergency conditions, admission over the weekend has been associated with rising morbidity and mortality rates. However, different studies have provided conflicting results regarding the increased rates of mortality and morbidity for patients with intracapsular femoral fracture who were admitted over the weekend, compared to weekdays. This study investigated the effect of weekend admissions on the surgical outcomes of patients with intracapsular femoral neck fractures.Materials and Methods:We conducted a retrospective cohort study of all the patients who were admitted to our level-II trauma center with an intracapsular femoral neck fracture between January 2009 and June 2011. Admission was classified as at the weekend if it took place between 18:00 pm on Friday until midnight on Sunday or on bank holidays. We compared the mortality rates within 30 days and 6 months after surgery for weekday and weekend admissions. Secondary outcomes considered included length of hospital stay, postoperative complications, and reoperation rates. Statistical analysis was performed using logistic regression models, which were adjusted for patient and surgical characteristics.Results:In total, 315 patients met our inclusion criteria. The mean age of this group was 77.9 years (standard deviation ±13) and the female to male ratio was 5:2. The average follow-up period was 49 months. Under logistic regression analysis, weekend admission was not a significant independent risk factor for the 30-day mortality rate (odds ratio 1.85, 95% confidence interval, 0.74-4.62; P = .19). Seventy-seven patients admitted over the weekend were treated within 24 hours versus 125 patients for the weekday group (80.2% vs 57.9%; P = .005). There were no differences between the sample groups in relation to implant-related complications (24.9% vs 25.8%, respectively, P = .89) nor in relation to general complications (12% vs 18.6%, respectively, P = .06). The mean hospital stay of patients operated on during weekends or holidays was significantly shorter compared to patients operated on during weekdays (6.7 vs 8.5 days; P = .009).Conclusion:Patients with intracapsular femoral neck fractures who were admitted over the weekend at our trauma center did not have a higher risk of mortality or morbidity. Furthermore, temporary preoperative care provided over the weekend by an internal medical consultant can be safe and efficient even in the circumstances where there is a lack of dedicated geriatric support. The absence of an elective operating list at the weekend could be a potential factor in shortening waiting times for surgery for intracapsular femoral neck fracture at weekends and holidays.

Radiographic templating of total hip arthroplasty for femoral neck fractures.

The purpose of this study was to evaluate the use of pre-operative digital templating to minimize complications including limb length discrepancy (LLD), intraoperative fractures and early dislocations in patients with intracapsular femoral neck fractures. We retrospectively compared 23 patients undergoing total hip arthroplasty (THA) for intracapsular femoral fractures with pre-operative digital templating and 48 patients without templating. The mean post-operative LLD was significantly lower in patients who had pre-operative templating than in the control group (6.7 vs. 11.5mm, p = 0.023). Only three patients (13%) with templating had LLD greater than 1.5cm, compared to the 15 patients (31%) without templating (p = 0.17). In eight cases the final femoral stem size matched the templated size, while 19 patients were within two size increments. Complications included one dislocation and one intra-operative fracture in the control group. The present study demonstrated that careful pre-operative planning may reduce LLD in patients undergoing THA due to intracapsular hip fractures.

Early Operative Intervention Is Associated With Better Patient Survival in Patients With Intracapsular Femur Fractures But Not Extracapsular Fractures

The purpose of this study was to determine patients' survival after undergoing an early or delayed operation. We retrospectively assessed 1849 files of patients operated for proximal femoral fracture, divided into two diagnostic groups: intracapsular (n=640) and extracapsular (n=1209). 1163 (63%) were treated within 48h from hospital admission and 686 (37%) were treated >48h afterwards. Delayed operation in patients with intracapsular fractures was associated with a 1.8-fold excess risk for 1-year mortality (HR=1.83, P=0.008), while no effect was observed for patients with extracapsular fractures. Males had a higher HR for mortality in both diagnostic groups. Early surgical intervention is beneficial for intra-capsular femoral fractures; male gender and a high ASA score are associated with an increased mortality hazard risk.

Effect of integrity of the posterior cortex in displaced femoral neck fractures on outcome after surgical fixation in young adults

Aim To assess whether disruption of the posterior cortex of intracapsular femoral fractures leads to an increased incidence of complications following closed reduction and internal fixation by multiple cannulated screws in young adults. Methods A total of 146 consecutive adult patients with 146 femoral neck fractures were treated by closed reduction and internal fixation with parallel cannulated screw in inverted triangle or diamond configurations. All enrolled patients were divided into three groups: those with a non-displaced femoral neck fracture (Garden types I or II), those with a displaced femoral neck fracture (Garden types III or IV) but no posterior cortex disruption and those with a displaced femoral neck fracture (Garden types III or IV) and a disrupted posterior cortex. Results Based on an average follow-up of 4.76 years (range, 2–6 years), displaced femoral neck fractures with a disrupted posterior cortex demonstrated an increased risk for avascular necrosis of the femoral head, shortening, redisplacement and conversion of prosthetic replacement as compared with those fractures without posterior cortex disruption ( p = 0.002, 0.016, 0.001 and <0.0001, respectively). Conclusions As compared with a femoral neck fracture with an intact posterior cortex, a displaced femoral neck fracture with a disrupted posterior cortex increases the risk for avascular necrosis, redisplacement and shortening and raises the likelihood that prosthetic replacement will be needed. Orthopaedic surgeons should be aware of this prognostic factor.

Warwick Hip Trauma Study: a randomised clinical trial comparing interventions to improve outcomes in internally fixed intracapsular fractures of the proximal femur. Protocol for The WHiT Study

BackgroundControversy exists regarding the optimal treatment for patients with displaced intracapsular fractures of the proximal femur. The recognised treatment alternatives are arthroplasty and internal fixation. The principal criticism of internal fixation is the high rate of non-union; up to 30% of patients will have a failure of the fixation leading to revision surgery. We believe that improved fracture healing may lead to a decreased rate of failure of fixation. We therefore propose to investigate strategies to both accelerate fracture healing and improve fixation that may significantly improve outcomes after internal fixation of intracapsular femoral fractures. We aim to test the clinical effectiveness of the osteoinductive agent platelet rich plasma and conduct a pilot study of a novel fixed-angle fixation system.DesignWe have planned a three arm, single centre, standard-of-care controlled, double blinded, pragmatic, randomised clinical trial. The trial will include a standard two-way comparison between platelet-rich plasma and standard-of-care fixation versus standard-of-care fixation alone. In addition there will be a subsidiary pilot arm testing a fixed-angle screw and plate fixation system.Trial RegistrationCurrent Controlled Trials ISRCTN49197425

Internal fixation versus arthroplasty for intracapsular proximal femoral fractures in adults

Displaced intracapsular fractures may be treated by either reduction and internal fixation, which preserves the femoral head, or by replacement of the femoral head with an arthroplasty. To review all randomised controlled trials that have compared internal fixation with arthroplasty for intracapsular femoral fractures in adults. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2005, Issue 4), MEDLINE, EMBASE, the UK National Research Register, several orthopaedic journals, conference proceedings and reference lists of articles. We contacted trialists where possible. All randomised and quasi-randomised controlled trials comparing internal fixation with arthroplasty for intracapsular hip fractures in adults. Trial quality was assessed by use of a 10 item scale. At least two review authors independently assessed trial quality and extracted data. Additional information was sought from trialists. After grouping into three broad categories, comparable groups of trials were subgrouped and where appropriate, data were pooled using the fixed-effect model. Seventeen trials involving 2694 participants were included. Length of surgery, operative blood loss, need for blood transfusion and risk of deep wound infection were significantly less for internal fixation compared with arthroplasty. Arthroplasty had a significantly lower re-operation rate in comparison with fixation. No definite differences for hospital stay, mortality, or regain of same residential state were found. Limited information from some studies suggested pain was less and function was better for a cemented arthroplasty in comparison to fixation. Internal fixation is associated with less initial operative trauma but has an increased risk of re-operation on the hip. Definite conclusions cannot be made for differences in pain and residual disability between the two groups. Future studies should concentrate on better reporting of final outcome measures and there is still a need for studies to define which patient groups are better served by the different treatment methods.

Two cannulated hip screws for femoral neck fractures: treatment of choice or asking for trouble?

Undisplaced intracapsular fractures are predominantly treated with a minimally invasive fixation technique, whereas the standard treatment for displaced intracapsular fractures is still a subject of discussion. The purpose of this study was to identify the determinants influencing the outcome of intracapsular femoral neck fractures, treated with two cannulated hip screws. From January 1998 through December 2002 data of all consecutive patients with an intracapsular femoral fracture, treated with two cannulated screws, were documented. Consolidation was chosen as the primary endpoint, mortality and a reoperation for replacement of osteosynthesis were defined secondary endpoints. One hundred and twelve patients were included in the study. Fifty six percent of the intracapsular fractures healed within 1 year. Consolidation was accomplished in 95% of the stable fractures. Consolidation rates were negatively influenced by unstable fractures and inadequate anatomical reduction. The position of the screws did not influence consolidation rates. Reintervention rates were related to the number of local complications and the fracture type. In conclusion, the results of this study show that in case of operative treatment, undisplaced femoral neck fractures can be adequately fixated by two cannulated hip screws. Unstable, anatomically reduced femoral neck fracture (Garden III/IV) may be treated with a more stable implant (e.g. DHS) to avoid redisplacement. If adequate reduction cannot be achieved, endoprosthetic replacement is recommended.

Management of intracapsular femoral neck fractures in the elderly; is it time to rethink our strategy?

We reviewed 100 adult patients who had a traumatic intracapsular femoral fracture internally fixed prior to 1998, with full clinical and radiological data available. End points were complete clinical and radiological union of the fracture, non-union, avascular necrosis or fixation failure. The incidence of non-union and avascular necrosis was found to be 13 and 11%, respectively. The following factors did not influence the development of avascular necrosis or non-union; fracture displacement, screws inserted (two or three), osteoporosis, parallelism of screws, presence of screws in each “quadrant” and the experience or seniority of the surgeon. The factors influencing a poor outcome were the age of the patient at injury, reduction gap at the fracture site, alignment after reduction of the fracture especially on AP view and having all screw threads crossing beyond the fracture site. We conclude that the incidence of non-union and avascular necrosis following fixation of femoral neck fractures in our study is less than generally reported with no statistical difference between displaced and undisplaced fractures. Traditional fixation factors such as screw position and number do not seem to significantly affect the outcome with the quality of reduction being most important. Thus, the majority of patients under the age of 70 with displaced intracapsular fracture should be considered for internal fixation.

Sub- or Intertrochanteric Fracture Following Screw Fixation of an Intracapsular Proximal Femoral Fracture: True Complication or Technical Error?

To review, retrospectively, the possible causes of sub- or intertrochanteric fractures after screw fixation of intracapsular fractures of the proximal femur. Eighty-four patients with an intracapsular fracture of proximal femur were operated between 1995 and 1998 by using three cannulated 6.25 mm screws. The screws were inserted in a triangular configuration, one screw in the upper part of the femoral neck and two screws in the inferior part. Between 1999 and 2001, we use two screws proximally and one screw distally. In the first series, two patients died within one week after operation. Sixty-four fractures healed without problems. Four patients developed an atrophic non-union; avascular necrosis of the femoral head was found in 11 patients. Three patients (3.6%) suffered a sub- and/or intertrochanteric fracture after a mean postoperative time of 30 days, in one case without obvious trauma. In all three cases surgical revision was necessary. Between 1999 and 2001 we did not observe any fracture after screwing. Two screws in the inferior part of the femoral neck create a stress riser in the subtrochanteric region, potentially inducing a fracture in the weakened bone. For internal fixation for proximal intracapsular femoral fracture only one screw must be inserted in the inferior part of neck.

Austin–Moore hemiarthroplasty for failed osteosynthesis of intracapsular proximal femoral fractures

We studied the outcome of 100 uncemented Austin–Moore hemiarthroplasties used as a revision procedure for failed osteosynthesis of intracapsular femoral fractures. This group was compared with 730 patients in whom an uncemented Austin–Moore prosthesis had been used as the primary treatment for an intracapsular femoral fracture. The results indicate that the study group had more pain at 1-year post-fracture. There were also significantly more revision procedures in those who had the arthroplasty performed as a salvage procedure. In general, the results of uncemented Austin–Moore hemiarthroplasty used as a revision procedure for failed osteosynthesis are inferior to that for primary hemiarthroplasty. We would advocate that for any case in which there are signs of acetabular damage a total hip replacement might be a better procedure. For the remainder, an alternative arthroplasty should be considered with an uncemented Austin–Morre prosthesis reserved for only the very frail.

Does the level of an intracapsular femoral fracture influence fracture healing after internal fixation? A study of 411 patients

The aim of the study was to determine if the level of an intracapsular femoral fracture influences the risk of non-union or avascular necrosis occurring after internal fixation. An observer blinded to the outcome of the treatment (fracture union, non-union or avascular necrosis) reviewed the radiographs of 411 patients with an intracapsular fracture, which had been treated by internal fixation. The level of the fracture was determined by two methods, a direct distance measurement and a ratio method. In addition, the diameter of the femoral head was measured. Results indicated that none of the methods for determining the fracture level had any relationship to the risk of non-union or avascular necrosis occurring. Undisplaced fractures were found to be more proximally located than displaced fractures. We conclude that the level of an intracapsular fracture should not be used as a method of deciding if the femoral head should be preserved or replaced. The level of an intracapsular fracture may determine if the fracture displaces at the time of injury.

Parallel Garden screws for intracapsular femoral fractures

One hundred and eighty-five patients with an intracapsular femoral fracture were prospectively studied and followed up until 1 year after injury. All patients were treated by fixation with parallel Garden screws. Fracture union occurred in 82 per cent of patients. Non-union was more frequent in displaced fractures, when the reduction was inadequate and when the screws were placed superiorly or anteriorly in the femoral head. Neither age nor sex were significantly associated with non-union.

Hemiarthroplasty and histopathological changes in the femoral head and joint capsule in intracapsular femoral fractures

This study aimed to investigate the histopathological changes occuring in the femoral head and joint capsule of the hip in 15 patients with intracapsular femoral fracture. The mean age of patients was 69,5 and, 14 had undergone hemiarthroplasty with Thompson endoprosthesis while 1 patient had total hip arthroplasty. Femoral heads and joint capsules were removed for histopathological investigation intraoperatively. Early findings evident of ischemic necrosis were discovered in 12 patients (80%). The fracture age was not found to be related with these changes (5 day-9 month). Hemiarthroplasty indications in elderly patients with femoral neck fractures were discussed and emphasized.

Immediate Moore prosthetic replacement in acute intracapsular fractures

Ninety-two cases of displaced subcapital and high transcervical fractures of the femur were treated by immediate Moore prosthetic replacement. These patients were mostly past the sixth decade of life. In both the service and private patients the procedure has been satisfactory. Surgical complications have been minimal, and morbidity and mortality are comparable to that of simple Smith-Petersen nailing. The disappointments of aseptic necrosis and mechanical failure that accompany the latter procedure have been avoided. Prosthetic replacement in individuals of waning years for displaced intracapsular femoral fractures is a rational step in the difficult problem of fractures of the hip.