Neck Fractures In Young Adults Research Articles

Evidence based update: Open versus closed reduction

Outcomes after operative treatment of displaced femoral neck fractures in young adults are fraught with high complications rates including non-union and avascular necrosis. Among the therapeutic controversies that persist is the role of open reduction, which would allow surgeons a direct means to improve the quality of reduction, a predictor of successful treatment. We performed a systematic review of the literature to compare the outcomes (nonunion, avascular necrosis, and deep infection) after open reduction with internal fixation (ORIF) to closed reduction with internal fixation (CRIF) of acute (surgery performed less than 6 weeks from injury) femoral neck fractures in young adults (average age of 50 or younger) followed for at least one year. Despite the large literature investigating outcomes after operative treatment of femoral neck fracture, relatively few studies aimed to determine the relative risk of complications associated with method of reduction. Therefore, both observational and randomised studies as well as case series with clear descriptions of surgical approach and outcomes were included. We identified 21 studies that matched our inclusion criteria. The incidence of nonunion was 11.6% in closed reduction and 14.9% in the open reduction group (P=0.25). The incidence of avascular necrosis for CRIF and ORIF were 17.2% and 17.7% respectively (P=0.91). The incidence of deep wound infection was 0.49% in the closed reduction group and 3.9% in the open reduction group (P=0.0019). Meta-analysis of risk ratios estimated from six of the studies with comparative data revealed no significant difference in the incidence of nonunion, avascular necrosis or total complications between the two reduction techniques. In summary, systematic review of the literature reveals a lack of evidence in support of ORIF versus CRIF as a means of treating displaced femoral neck fractures in young patients with respect to union and avascular necrosis; however, the incidence of surgical site infections may be lower with CRIF. Firm conclusions cannot be drawn given the lack of high quality prospective studies and patient reported outcomes. In the future, randomised controlled trials will be required to test the effect of reduction method.

Fracture Morphology of High Shear Angle “Vertical” Femoral Neck Fractures in Young Adult Patients

Management of vertical femoral neck fractures in young adults has been a challenging clinical problem, resulting in mixed clinical outcomes. A thorough understanding of the fracture morphology for this injury pattern is lacking, which may contribute to frequent failures of treatment. This study is designed to produce a detailed description of the pathoanatomy of these fractures, which may ultimately be helpful in developing more informed reduction and fixation strategies. Retrospective study of patient records, plain radiographs, and computed tomography scans to determine the morphology the Pauwels III femoral neck fractures (coronal angle >50 degrees) in young adults. Two level I and 1 level II regional trauma centers. All patients 18-49 years of age with a surgically repaired, high-energy high shear angle (>50 degrees) femoral neck fracture from January 1, 2007, to December 31, 2010. One hundred thirty-six adult patients younger than 50 years were identified with a femoral neck fracture in the study period, of whom 33 met all study criteria. We evaluated plain radiography and computed tomography data including fracture orientation, comminution, deformity, characteristics of the inferomedial fracture spike, and the associated inferomedial calcar's cortical buttress. The vertical (coronal) fracture averaged 60 degrees and axial fracture obliquity averaged 24 degrees with relative deficiency of the posterior neck on the head-neck fragment. Major femoral neck comminution (>1.5 cm in any dimension) was identified in 96% of cases, mostly located in the inferior (94%) and posterior (82%) quadrants. The apical fracture spike of the head segment was found to be in line (within 10 degrees) of the neck-shaft axis on the proximal femur 63% of the time. Deformity in external rotation averaged 44 degrees (range, 10-68 degrees) and shortening of the femur averaged 1.8 cm (range, 0.9-4.4 cm). This study investigated the fracture morphology of isolated, high shear angle femoral neck fractures in young adults, which may ultimately lead to improved operative reduction and fixation tactics. Given this injury's characteristic findings, including fracture orientation, deformity, and comminution, surgeons should be cognizant of this pattern's innate instability and potential for treatment failure with typical implant constructs.

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

To evaluate the role of quadratus femoris muscle pedicle bone grafting along with open reduction and internal fixation in the treatment of neglected and ununited femoral neck fractures in young adults. Young adults within the age group of 15-45 years with ununited, old neglected fractures of femoral neck were included in the study. All patients underwent quadratus femoris muscle pedicle bone grafting along with open reduction and internal fixation. The post-operative complications and functional recovery was assessed using Charnley's modification of Merle D'Aubigne and Postel hip scoring. A total of 17 patients were included in the study. The average time of union following the procedure was found to be approximately 8 months. There were two cases of delayed union and no cases of avascular necrosis. Ten patients (58.8%) had excellent or very good post-operative functional results and 6 patients (35.3%) had good or satisfactory results. Muscle pedicle bone grafting is a useful adjunct to open reduction and internal fixation for ununited femoral neck fractures. It achieves good final functional results comparable with other methods, but requires greater expertise.

Evaluation of osteosynthesis with dual fibular bone grafting for neglected femoral neck fractures.

Femoral neck fractures in young adults is an unsolved problem and neglected femoral neck fractures presents more challenge to the orthopaedics surgeon if femoral head salvage is attempted. We reviewed the operative results of neglected femoral neck fractures in young adults with fixation with dual fibular bone grafting Purpose of study was evaluation of epidemiological, clinical, functional, rehabilitative outcome and complications in such patients. Twentyeight patients in age group 18-50 years were operated having fracture neck femur by dual fibular bone grafting in the Department of Orthopaedics, S.N. Medical College, Agra in (May 2005-February 2008) and divided into two groups. Group A: comprised of 8 patients treated by dual fibular bone grafting alone and Group B: comprised of 18 patients treated by dual fibular bone grafting with single cancellous hip screw. All the patients of the present series were having neglected intracapsular fracture, neck femur which were treated by dual fibular bone grafting with or without cancellous hip screw fixation. Majority of the patients had good to fair result according to Larson method with average time of union 16 weeks. All patients had useful range of movement at hip. Satisfactory union was achieved in all patients except two. Double bone grafting is a simple and cost effective modality of treatment for late femoral neck fracture with good results. It is a stable and biological method of fixation with preservation of natural femoral head with fewer complications.

Evaluation of valgus intertrochanteric osteotomy in neglected fracture neck femur in young adults.

Femoral neck fractures in young adults have always presented a difficult problem with high rates of non-union and avascular necrosis. At our centre we have been using the traditional Pauwels intertrochanteric osteotomy for neglected un-united femoral neck fractures in young adults. We have made certain modifications in this procedure to suit our resources and so we evaluated the outcome of this procedure at our institute. The study included fifty consecutive cases of neglected femoral neck fractures treated at our centre between February 1996 and October 2012. Patients in whom internalfixation had failed were excluded. The average age of the patients was 37 years (range: 17-55 years). Eleven of the patients were female & Thirty-nine were male. Fifteen patients belonged to Pauwels grade 1, Twenty-six patients belonged to grade 2, and nine belonged to grade 3. The interval between the injury and operation ranged from 1 to 12months (average: 4.3 months). The cases were operated on a normal table using a Watson Jones Approach. The fracture ends were freshened and fixed using a 6.5mm screw followed by a valgus osteotomy which was fixed by a double angle (120 degree) blade plate. A fracture union rate of 90% (45 cases) was achieved. Two of the healed cases developed avascular necrosis. Results were graded using Askin and Bryan's criteria. Overall, an excellent result was seen in 35 patients, good in 5, fair in 5 and poor in 5. Of the five patients having poor result (3 non-union, 1 implant breakage, 1 implant cut out), two refused revision surgery. In remaining three, one underwent total hip arthroplasty and in two revision osteotomy was performed. We believe that intertrochanteric osteotomy provides a good outcome for neglected femoral neck fractures. Performing the procedure on a routine table, with Watson Jones approach and fixing with double angle blade plate is a good option.

Outcomes of open reduction, and internal fixation in femoral neck fractures in young adults

Outcomes of open reduction, and internal fixation in femoral neck fractures in young adults

Prospective and Comparative Analysis of Internal Fixation of Femoral Neck Fractures With or Without Vascularized Iliac Graft in Young Adults

The purpose of this study was to compare the effectiveness of 2 surgical approaches for femoral neck fractures in young adults: internal fixation with or without a vascularized iliac graft. Between January 1998 and December 2008, seventy-eight patients presented with a Garden type III (n=38) or IV (n=40) femoral neck fracture. Thirty-eight patients were women and 40 were men, with an average age of 28 years (range, 16-38 years). Fractures were caused by fall injury (n=24), motor vehicle accident (n=36), and heavy weight lifting (n=18). Patients were randomly divided into 2 groups. Group A underwent internal fixation with 2 cannulated compression screws combined with an iliac graft supported by the ascending branch of the lateral femoral circumflex artery (n=44), and group B underwent internal fixation with 3 cannulated compression screws (n=34). Average follow-up was 4.5 years (range, 2-8 years), and mean Harris Hip Score was 92 (range, 62-100) in group A and 84 (range, 40-100) in group B. Average fracture healing time at final follow-up was 4.4 months in group A and 6 months in group B. Two (4.5%) cases of osteonecrosis of the femoral head occurred in group A, and 8 (23.5%) cases occurred in group B. Internal fixation with 2 cannulated compression screws combined with an iliac graft supported by the ascending branch of the lateral femoral circumflex artery is an effective surgical approach for treating femoral neck fractures in young adults to minimize the occurrence of fracture nonunion and osteonecrosis of the femoral head and to facilitate bone healing and functional recovery of the hip.

Neglected neck femur fractures in adolescents and young adults: factors predicting the surgical outcome

BackgroundNeglected femoral neck fracture in young adults is an intriguing problem. This retrospective study tried to solve that challenge through open reduction, cannulated screw internal fixation, autogenous iliac bone and bone marrow grafting. MethodsThirty-six cases were studied; they were classified according to Sandhu et al.'s classification. Twenty cases were type I and 16 cases were type II fractures; the mean age was 26.8years; fracture neglect averaged 44.6days. Twenty cases had posterior comminution and 16 cases had anterior comminution. All cases had open reduction, cannulated screw internal fixation, autogenous iliac bone and bone marrow grafting. The Harris hip score and Matta et al. grading system were applied for functional and radiological evaluation, respectively. ResultsThe average postoperative follow-up was 25.3months; 94.4% of the cases had solid union in a mean of 19.6weeks. Functionally, the Harris hip score averaged 87.8 points. Nonunion, avascular necrosis and coxa vara complicated two, two and four cases, respectively. Fair and poor radiological results were related to coxa vara and avascular necrosis, respectively. Nonunion was significantly related to posterior comminution, type II neglected fracture, and a neglect of more than 45days. Age groups more than 30years old and postoperative neck-shaft angles <140° were significantly associated with late-onset radiological healing and nonunion. ConclusionsCannulated screw osteosynthesis augmented by autogenous bone and bone marrow grafting is a simple, easy-to-perform surgical procedure with encouraging clinical outcomes for selected patients complaining of that difficult problem.

Free Vascularised Fibular Graft for Neglected Femoral Neck Fractures in Young Adults

Neglected femoral neck fractures in young adults pose a great challenge to orthopedic surgeons because of the high risks of nonunion and osteonecrosis. We attempted to determine whether free vascularised fibular grafting through an anterior approach could enhance bone union, improve hip function and reduce complications in the treatment of such fractures. Thirteen patients with neglected femoral neck fractures were treated with a free vascularised fibular graft through an anterior approach between 2004 and 2008. The mean age was 30.9 years (range, 17-47 years). The average delay between injury and operation was 6.7 months (range, 1.5-22 months). All 13 cases had ununited fractures but without osteonecrosis of the femoral head on plain radiographs before coming under our care. The average follow-up was 51.2 months (range, 36-75 months). All patients had fracture union within an average of 4.8 months (range, 3-9 months). Postoperatively, 9 patients had coxa vara of 10 to 20 degrees and leg discrepancy between 0.5 to 1.5 cm. One patient had coxa vara deformity of 25 degrees and 2-cm leg discrepancy. No patients developed osteonecrosis of the femoral head or donor-site morbidity. The mean Harris hip score improved from 55.5 points preoperatively to 84.8 points postoperatively (p<0.01). This procedure may be useful and safe in the treatment of neglected femoral neck fractures in young adults, but further studies with a large number of patients are needed.

Outcome of cloverleaf locking plate fixation for femoral neck fractures in young adults.

Femoral neck fractures in young adults remain a major problem in orthopaedics. Although treatments using cannulated screws and sliding hip screws are widely accepted, they pose significant clinical challenges. In the present study, we evaluated the outcome of treatment using cloverleaf locking plate fixation (augmented with the addition of addition of nonvascularised autologous bone grafts for neglected fracture). Fourteen patients were investigated in this cross-sectional study. Union times and Harris hip scores were analysed by independent T-test based on displacement (displaced vs. nondisplaced) and type (acute vs. neglected) of fracture. No difference in union time was found between acute and neglected groups and between nondisplaced and displaced fractures. Harris hip scores were similar between acute and neglected groups and between non- and displaced group. Cloverleaf locking plate fixation is a viable alternative method for stable fixation of femoral neck fractures in young adults. Femoral neck fracture, young adult, cloverleaf locking plate, Harris hip score, union rate.

Injury-to-surgery interval does not affect postfracture osteonecrosis of the femoral head in young adults: a systematic review

Osteonecrosis of the femoral head (ONFH) is a common and severe complication following femoral neck fractures in young adults. Despite significant advances in surgical techniques, radiological evaluation and comprehensive treatment for the prevention of ONFH, the incidence of traumatic ONFH has remained unchanged at approximately 20% in recent decades. The injury-to-surgery interval is considered as a principal factor affecting the occurrence of ONFH, and traditionally, femoral neck fractures are treated emergently. However, the relationship between the injury-to-surgery interval and ONFH occurrence is poorly understood, and previous reviews have not provided a precise explanation due to the lack of strict selection criteria for studies. We reviewed previously published articles and included in current systematic review those studies with accurate multivariate analyses that included age, fracture type, operation method, follow-up, ONFH occurrence and injury-to-surgery interval. Six case studies were included and reevaluated. The studies included 263 hips for final analysis, with an overall incidence of postfracture ONFH of 17.5%. Patients were categorized into groups of less/more than 8h, less/more than 24h, less/more than 48h and less/more than 3weeks based on the individual injury-to-surgery interval. The postfracture ONFH incidence ranged from 13.3% (<8weeks) to 21.7% (>3weeks). Operations performed within 3weeks of injury resulted in a lower ONFH incidence compared with operations performed after 3weeks; however, this difference was not statistically significant. The ONFH incidence remained relatively stable when the operations were performed within 3weeks of injury. The injury-to-surgery interval did not significantly affect the incidence of postoperative ONFH.

Hollow-Bone-Graft Dynamic Hip Screw Can Fix and Promote Bone Union after Femoral Neck Fracture: an Experimental Research

Background: Delayed bone union, nonunion or osteonecrosis often occur after femoral neck fractures in young adults. Secondary bone healing requires strong internal fixation, intramedullary pressure reduction and early functional exercise.Objective: To compare bone healing of femoral neck fractures treated with hollow-bone-graft dynamic hip screws (Hb-DHS) and standard dynamic hip screws (DHS) in an animal model.Design: Testing of specifically designed fixation devices in a pig animal model.Interventions/Methods: We designed Hb-DHS and DHS devices appropriate to the femoral neck and head of experimental animals and used them in eight pigs (4-month-old, male or female, 30-40 kg/each). Under anesthesia, we induced medium neck type, Garden III type femoral neck fractures in each pig with fracture gaps of 0.5 mm and then fixed each left femur with Hb-DHS and each right femur with DHS. We assessed the animals radiographically and by postmortem visual appraisal of evidence of bone healing 8 and 16 weeks postoperatively.Results: There were significant differences in radiographic and general findings between the Hb-DHS and DHS groups at weeks 8 and 16 postoperatively. We found statistically significant differences between the Hb-DHS and DHS groups in bone healing scores, trabecular bone volume percentage and bone mineral density as assessed on plain radiographs and computed tomography images (P < 0.05). There were also significant differences between the Hb-DHS and DHS groups in postmortem visually assessed indicators of bone healing at both 8 and 16 weeks postoperatively.Conclusions: The Hb-DHS device promotes femoral neck bone union, stimulates trabecular bone formation, increases BMD and has advantages over DHS for internal fixation of femoral neck fractures. This animal experiment will contribute to developing optimal treatment for femoral neck fractures in young adults.

Management of Intracapsular Femoral Neck Fractures in Adults Younger Than 65 Years

Purpose The study is to review the results of intracapsular femoral neck fractures in young adults (age < 65) treated with reduction and multiple-screw fixation from 2000 to 2007. Method Sixty-four consecutive patients were reviewed retrospectively. The mean age of the patients at the time of injury was 53.5 (32–65) years old. All fractures were either closely or openly reduced and fixed with three 7.5-mm cancellous screws. The mean follow up period was 36.8 months (6–100). Results We found that 9 of 64 (14.1%) patients developed osteonecrosis of femoral head on follow up. Displacement of fracture (Garden classification), initial stability of fracture pattern (Pauwel classification), and quality of reduction (Haidukewych grading) were found to have significant effect on the development of osteonecrosis, whereas the effect of patient age, time lapse of surgery, capsulotomy, hip aspiration, and postoperative weight bearing regimen were not statistically significant. Conclusion Fracture pattern and quality of reduction govern the fate of the femoral heads in young adults with their intracapsular femoral neck fractures fixed with screws.

Treatment of Serious Femoral Neck Fractures with the Transposition of Vascularized Greater Trochanter Bone Flap in Young Adults

Femoral neck fractures in young adults are not uncommon in clinical work. For fresh fractures or old femoral neck fractures of subcapital type or Garden types III to IV, femoris caput necrosis and nonunion are apt to occur if conventional therapeutic method is adopted and direct joint replacement is attempted. However, this has brought about bitter controversies in medical circles. The authors of this article define such fractures as serious femoral neck fractures. What kind of operational method should be selected, to the maximum extent, to restore the function of hip joints of patients and reduce their complications after operation still remains a problem to be studied. In this article, cases of patients (from 1999 to today) treated with transposition of vascularized greater trochanter bone flap and hollow compression strews are analyzed. Patients were followed for 39 to 84 months, and the results are summarized.

Displaced Femoral Neck Fractures in Young Adults Treated with Closed Reduction and Internal Fixation

This article describes the effect of closed reduction and internal fixation with 3 different screw configurations for acute completely displaced femoral neck fractures in young adults. From 2001 to 2006, 136 patients (age range, 20-50 years) who had acute unilaterally completely displaced femoral neck fractures were evaluated retrospectively. All fractures were managed with closed reduction and internal fixation with 3 cannulated screws. The follow-up period was 55 months on average (range, 36-90 months). One hundred twenty-two patients were available for final evaluation of union condition and late complication. Twenty-three patients (18.9%) had nonunion, 15 (12.3%) had fixation failure, and 21 (17.2%) had avascular necrosis of the femoral head. The average duration from injury to surgery was 18.4 hours in the union group and 23.3 hours in the nonunion group, with no statistical significance (P=.196). The average duration from injury to surgery was 17.3 hours in the avascular necrosis of the femoral head group and 22.3 hours in the non-avascular necrosis of the femoral head group, with no statistical significance (P=.155). Vertical- and separated-type screw configurations resulted in a significantly higher nonunion rate (P=.001 and P=.0017, respectively) than parallel configuration. The complication rate in treating completely displaced femoral neck fractures with internal fixation in young adults is high, and screw configuration may further affect results.

青壮年者 (40～59歳) の大腿骨頚部骨折に対する骨接合術の治療成績

青壮年者 (40～59歳) の大腿骨頚部骨折に対する骨接合術の治療成績

若年成人の大腿骨頚部内側骨折に対する徒手整復および骨接合手術の小経験

若年成人の大腿骨頚部内側骨折に対する徒手整復および骨接合手術の小経験

Treatment of femoral neck fractures in young adults

Objective To explore the surgical procedures and efficacy for femoral neck fractures in young adults. Methods 41 young adults with femoral neck fracture were treated in our department from January 2005 to June 2008 and were followed up according to the research standards for refractory fractures. Close reduction and internal fixatian with titanium cannulated screws were adopted for Garden types Ⅱ & Ⅲ. Open re-duction and internal fixation with titanium cannulated screws plus iliac grafting were adopted for Garden type Ⅳ and obsolete and pathologic fractures. The clinical efficacy was evaluated in terms of fracture type, implants, fracture reduction, postoperative bed-ridden time and hip functional recovery. Results All the 41 cases were followed up for 10 to 52 months, with an average of 30.5 months. 90.2% of the cases were treated surgically from 2 to 5 (mean, 3.6) days after injury. Reduction evaluation scored 4. 83 points on average. The average bed-ridden time was 3.5 months after surgery. According to Harris scoring for hip function, the result was excellent in 21 cases, good in 15, fair in 3, and bad in 2, with the excellent-to-goad rate of 87.8%. The excellent-to-goad rate of Garden type Ⅳ is lower than those of Garden types Ⅱ & Ⅲ, and there is no statistical significance. Between them(χ2 = 1.35, P = 0.25) . Conclusions Early surgery, anatomical reduction, stable fixation with titanium cannulated screws are the key to successful treatment of femoral neck fracture in young adults. Efficient iliac flap grafting, early activities and later weight-beating can prevent avascular necrosis of femoral head. Key words: Femoral neck fracture; Fracture fixation, internal; Retrospective study

Free fibular strut graft in neglected femoral neck fractures in adult

Background:Neglected femoral neck fracture in adults still poses a formidable challenge. Existing treatment options varies from osteotomy (with or without graft) to osteosynthesis using various implants and grafting techniques (muscle pedicle, vascularized, and nonvascularized fibula). The aim of this study was to assess outcome of nonvascularized fibular strut graft and cancellous screw fixation in neglected femoral neck fractures in the younger age group.Materials and Methods:Medical records of 32 patients of neglected femoral neck fracture, in the age group of 22-45 years (mean 37.8 years), operated between May 1994 to December 2001, were retrospectively reviewed. After the application of inclusion and exclusion criteria, 28 patients having three years minimum follow-up (mean 4.6 years) were included. Delay between injury and operation varied from four weeks to 42 weeks (mean 16.4 weeks). Closed reduction was achieved in 17 patients; open reduction through Watson-Jones anterolateral approach was performed in the remaining 15 patients in whom closed reduction failed. The fracture was transfixed with three parallel guide wires. Appropriate sized cannulated lag screw (7 mm) was then inserted in two of the wires. Selection of the third guide wire for fibula depended on the space available in both anteroposterior and lateral view.Results:Satisfactory bony union was obtained in 25 patients, of whom in four cases, the union occurred in 10-20° (mean 15°) of varus. Nonunion occurred in three patients (9.37%), and aseptic necrosis occurred in another six patients (18.75%). Of the 25 patients where union was achieved, five patients showed excellent results; 14 good and six had poor functional result, as evaluated using modified Anglen criteria.Conclusion:Nonvascularized fibular strut graft along with cancellous screws provides a dependable and technically less-demanding alternative procedure for neglected femoral neck fractures in young adults. Fibula being cortical provides mechanical strength besides stimulating the union and getting incorporated as biological graft.

The Neglected Femoral Neck Fracture in Young Adults: Review of a Challenging Problem

A neglected femoral neck fracture is one where there has been a delay of more than 30 days to seek medical help from the time of the original injury. Among the spectrum of femoral neck fractures, the neglected fracture in a young adult (age <60 years) is one of the most challenging to treat if femoral head salvage is attempted. The main complication is avascular necrosis (AVN) of the femoral head with most reported incidences being <15% (range 0% to 67%), which is similar to the complication rate with non-neglected femoral neck fractures. This review consolidates our current knowledge about the problem, discusses the various treatment options and compares the published long-term results. There are no clear guidelines for management of neglected femoral neck fractures, although multiple methods have been used with varying success. Bone grafting or internal fixation in isolation does not provide a satisfactory outcome. Osteotomy has given better outcomes (AVN 6% to 17%, non-union 0% to 15%), but mechanical changes at the femoral neck may lead to a persistent painful hip. Bone grafting with internal fixation has emerged as a reliable method with good long-term functional outcomes.