Femoral Neck Fracture Patients Research Articles

Clinical significance of trabecular bone score of DXA in hip fracture patients-comparative study between trochanteric fractures and neck fractures

BackgroundStudies have shown that the clinical efficacy of TBS (Trabecular Bone Score) of DXA in hip fracture patients. This study aimed to investigate the difference of TBS in trochanteric fractures and femoral neck fractures in hip fracture patients.MethodsData were derived from the University affiliated hospital, the participants included 249 patients aged 60 years or older who were available of TBS prescribe by DXA. 89 femoral neck fracture patients and 160 trochanteric fractures were enrolled. Spine T- score, hip T- score (neck), hip T- score (total), lowest T- score in hip, L1-L4 TBS. TBS Z-score, L1-L4 BMD(g/cm²), L1-L4 BMD T-score, L1 TBS, L1 BMD(g/cm2), L1 BMD T-score, L2 TBS, L2 BMD(g/cm2), L2 BMD T-score, L3 TBS, L3 BMD(g/cm2), L3 BMD T-score, L4 TBS, L4 BMD(g/cm2), L4 BMD T-score, lowest TBS score, highest TBS score were analyzed.ResultsDemographic data (age, sex, height, weight, BMI) and T-score of hip and spine in two groups showed no significant difference. TBS in spine in two groups revealed higher TBS in femoral neck fracture groups. ConclusionThere is no difference of age, sex, and BMI in two groups. The T-score was not statistically significant in comparison of bone quality in hip fracture groups. The TBS in femoral neck fracture group is higher than trochanteric fractures. The TBS in spine can be more valuable than T-score of DXA for the proper evaluation of bone quality in the hip fracture patients.

Cemented Hemiarthroplasty Results in Substantial Cost Savings Over Uncemented Hemiarthroplasty for the Treatment of Femoral Neck Fractures in Patients Over 60 Years Old: A Markov Analysis

BackgroundWhile there is growing scientific evidence supporting superior outcomes following cemented versus uncemented hip hemiarthroplasty (HHA) in elderly femoral neck fractures (FNFs), the relative cost-effectiveness of this in the United States is unknown. Thus, the purpose of this study was to compare the cost-effectiveness of cemented versus uncemented HHA for the treatment of FNFs in patients > 60 years old in the United States, accounting for postoperative outcomes including periprosthetic fractures. MethodsA Markov model utilizing Monte Carlo microsimulation was developed to evaluate the outcomes and costs of patients at least 60 years of age (mean ± standard deviation, 84 ± 8 years) undergoing cemented versus uncemented HHA for the treatment of FNFs. Health utility values, transition probabilities, and upfront costs were derived from the published literature. Outcome measures included average total costs associated with each treatment (including those from patients who sustained a periprosthetic fracture), quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio (ICER). ResultsMean total costs resulting from cemented and uncemented HHA were $19,462 ± 3,581 and $21,997 ± 3,574, respectively (upfront costs from the published literature were $18,267 for cemented HHA and $16,803 for uncemented HHA). Average QALYs resulting from cemented and uncemented HHA were 4.0 ± 0.7 and 3.1 ± 0.6. The resulting ICER was -$2,688.9/QALY. Cemented HHA was found to be the most cost-effective treatment strategy in 89% of the patients in the Monte Carlo microsimulation model. ConclusionDespite documented higher upfront costs for cemented HHA, the averaged total costs over a 10-year time horizon were $2,534 less for cemented HHA than for uncemented HHA. In addition, cemented HHA resulted in an additional 0.9 QALYs relative to uncemented HHA. The findings of this United States-based study replicate the financial and quality-of-life benefits of cemented HHA for elderly FNFs seen in other health systems.

Effects of Total Hip or Knee Arthroplasty on Median Survival in Patients Aged 80 Years and Older

During the 20th century, the life expectancy increased by 30 years. At the same time, the number of people living longer than that has grown significantly. The aim of this study was to investigate whether total hip or knee arthroplasty (THA or TKA) in patients over 80 years of age does not reduce their life expectancy. The study examined the data of patients who had undergone THA or TKA between 1994 and 2002 and were older than 80 years at the time of surgery. The study group was divided into a group of patients in whom elective total hip or knee arthroplasty was performed for arthritis and into a group of patients who underwent the same procedure for proximal femur fracture. The investigated parameter was the real survival, which was compared with the life expectancy predicted by the Institute of Health Information and Statistics of the Czech Republic. We also monitored postoperative mortality and postoperative interval after which the life expectancy was no longer reduced. The study included 547 patients. Of whom, 96 patients underwent elective surgery (36%) and 351 patients underwent surgery for intracapsular hip fracture (64%). In the elective surgery group, the survival was longer than the national average: In the 80-84-year group, the median survival was 6.0 years vs. median life expectancy of 5.6 years; in the 85-89-year group, the median survival was 6.3 years vs. median life expectancy of 3.9 years. The fracture surgery group showed a decrease in the life expectancy compared to the national average - in the 80-84-year group, the median survival was 3.5 years vs. median life expectancy of 5.6 years, and in the 85-89-year group, the median survival was 2.9 years vs. median life expectancy of 3.9 years. The likelihood of postoperative mortality was significantly higher in the fracture group than in the elective group (p = 0.05 vs. 0.01), with the difference being the highest in the first 8 weeks after surgery. Correctly indicated THA or TKA in patients over 80 years of age improves the quality of life of these patients and does not reduce the life expectancy. Intracapsular femoral neck fractures in patients of that age can still be considered as an indication for surgical treatment as a life-saving procedure. total hip arthroplasty, total knee arthroplasty, osteoarthritis, hip fracture, life expectancy.

Risk factors for nonunion in femoral neck fracture patients with internal fixation: A multicenter (TRON group) retrospective study

IntroductionFemoral neck fractures (FNFs) are common in elderly individuals. When minimally displaced, they are typically treated with internal fixation. Nonunion is a complication of internal fixation of FNF, that sometimes necessitates reoperation. Radiographic parameters, including the Pauwels angle and posterior tilt angle, are risk factors for nonunion. However, these parameters are assessed solely in a two-dimensional context. We developed a novel radiographic parameter named the “Kindex.” This multicenter investigation aimed to identify risk factors for nonunion following FNF fixation and evaluate the validity of this index. MethodsThis retrospective multicenter study collected data from 939 FNF patients who underwent internal fixation between 2016 and 2020 at 11 facilities (TRON group). The following exclusion criteria were applied: age <65, insufficient data, and Garden Stage III or IV fracture. Patient data, including age, sex, BMI, ASA classification, alcohol and smoking history, and comorbidities, were recorded. Radiographic measurements of the Pauwels angle and posterior tilt angle at the time of injury were used to calculate the Kindex. Correlations between the Pauwels angle, posterior tilt angle, Kindex, and nonunion were evaluated. A multivariate logistic regression analysis was performed to investigate independent risk factors for nonunion. A receiver operating characteristic (ROC) analysis was performed to determine the cutoff value of the Kindex, and the area under the curve (AUC) was calculated. ResultsThe study included 594 patients (males, n = 151; females, n = 443; average age, 80.9 years). Nonunion was observed in 13 cases (2.2 %). While the Pauwels angle and posterior tilt angle did not show significant correlations, the Kindex exhibited strong correlations with both parameters. In the multivariate analysis, the Kindex and renal impairment were independent risk factors for nonunion (Kindex: OR 1.06, p = 0.015; renal impairment: OR 1.48, p = 0.021). In the ROC analysis, a Kindex of 50 was identified as the optimal cutoff value (AUC 0.72). ConclusionThe nonunion rate after internal fixation of FNF was 2.2 %. Renal impairment and the Kindex were identified as independent risk factors. The Kindex at the time of injury may serve as a novel radiographic parameter to consider when evaluating the need for internal fixation in FNF cases.

ThP7.11 - Does Hypoalbuminaemia Increase the Risk of Surgical Site Infection in Neck of Femur Fracture Patients? A Systematic Review and Meta-analysis

Abstract Aim Serum albumin plays an important role in physiological and inflammatory haemostasis; low serum levels are linked with an increased incidence of surgical site infections (SSI). Although this has been demonstrated in spinal and elective arthroplasty surgeries, there is a paucity of evidence with regard to the effect of low preoperative serum albumin on rates of SSI following surgery for adult patients suffering from traumatic, acute hip fractures. Method A systematic review was conducted using the PRISMA guidelines. Four databases were searched for randomised controlled trials, cohort and case-controlled studies. The risk of bias was assessed using the Newcastle-Ottawa Score (NOS). Data was collected and pooled using RevMan Web Software. Results were reported as Odds Ratio (OR) with 95% Confidence Intervals (CI) and statistical significance of p &amp;lt;0.05. An Inverse-Variance model was used in meta-analysis. Results Six retrospective studies (five cohorts, one case-control) with a total of 43,059 patients were included. 45.3% (n=19,496) had low serum albumin (&amp;lt;3.5 g/dL). Hypoalbuminemia was associated with a significantly higher risk of any form of SSI (OR 1.25, p=0.008) and deep SSI (OR 1.76, p=0.05). There was no statistical significance between hypoalbuminemia and the incidence of superficial SSI (OR 1.06, p=0.77). Organ-space SSI was associated with hypoalbuminemia, albeit only one study reported this with poor statistical significance (OR 8.74, p&amp;lt;0.054). Conclusion Hypoalbuminemia increases the risks of most forms of surgical site infections; superficial and deep infections. There is a weak conclusion to draw between incidence of deep-space organ infections and low serum albumin.

Shall We Not Pressurise It? Effects of Bone Cement Pressurisation on Mortality and Revision Following Hip Hemiarthroplasty for Neck of Femur Fracture Patients: A Comparative Cohort Study.

This study aimed to compare 30-day post-operative mortality, and revision for aseptic femoral component loosening and all-causes following hip hemiarthroplasty performed with or without pressurisation of the bone cement in neck of femur fracture patients. Design: Retrospective cohort study. Level I trauma center. Patients ≥60 years with OTA/AO 31B who underwent a cemented hip hemiarthroplasty from 10th December 2007 (database inception) to 15th November 2023 (search date) were reviewed.Outcome Measures and Comparisons: Comparisons were made between patients who underwent hip hemiarthroplasty with versus without pressurisation of the bone cement for outcomes 30-day post-operative mortality, revision for aseptic femoral component loosening, and revision for all-causes. 406 procedures among 402 patients, and 722 procedures among 713 patients were performed with and without pressurisation of the bone cement respectively. Mean ages were 83.1 and 84.3 years (p=0.018), with 72.2% and 68.6% (p=0.205) females in the pressurised and non-pressurised cement patient groups respectively. There were no differences in 30-day post-operative mortality (7.2% versus 8.2%; HR 0.89, 95%CI 0.46-1.73, p=0.727). There were no differences in all-cause revision (HR 1.04, 95%CI 0.27-4.04, p=0.953). No revisions were performed for aseptic loosening. Survival at 10 years post-operatively was 15.3% (95%CI 11.46-19.64) and 12.6% (95%CI 7.67-18.82) among patients who underwent hemiarthroplasty with and without bone cement pressurisation respectively. There were no differences in 30-day post-operative mortality among patients who underwent hemiarthroplasty with, compared to, without bone cement pressurisation. Bone cement pressurisation did not confer any advantages for revision outcomes which may be attributed in part to patients' high mortality rate and low survival beyond 10 years post-operatively. Level III. See Instructions for Authors for a complete description of levels of evidence.

SURGICAL APPROACH IMPACTS PATIENT-REPORTED SYMPTOMS FOLLOWING ARTHROPLASTY FOR FEMORAL NECK FRACTURE

We aimed to examine outcomes between displaced femoral neck fracture (FNF) patients managed with total hip arthroplasty (THA) or hemi-arthroplasty (HA) via the anterolateral vs. posterior approach.We used data from the HEALTH trial (1,441 patients aged ≥50 with displaced FNFs randomized to THA vs. HA). We calculated each patient's propensity to undergo arthroplasty via the posterior approach, and matched them to 1 control (anterolateral approach) based on age (±5 years), and propensity score. We used Chi-Square/Fisher-Exact tests to compare dichotomous outcomes, and repeated measures ANOVA to examine differences in patient-reported outcomes (via the WOMAC subscores) from baseline to one-year postoperative. We used logistic regression to identify independent predictors of reoperation for instability in the posterior group.We identified 1,306 patients for this sub-analysis, 876 (67.1%) who received arthroplasty via an anterolateral approach, and 430 (32.9%) a posterior approach. The unadjusted rate of reoperation was significantly higher in the posterior group (10.7% vs. 7.1%).Following propensity score matching, we retained 790 patients (395 per group), with no between-group differences in patient, fracture, or implant characteristics. The matched cohort had a higher rate of comorbidities, and were less likely to be employed vs. the unmatched cohort. The rate of treatment for dislocation remained higher in the posterior group (6.1% vs. 2.0%) following matching.Repeated measures ANOVA revealed significantly better WOMAC pain, stiffness, function, and total scores in the posterior group. Between-group differences at 12-months were: pain - 0.59 (0.03–1.15); stiffness - 0.62 (0.35–0.87); function - 2.99 (0.12–5.86); total - 3.90 (0.24–7.56). We identified THA (vs. HA, odds ratio 2.05 [1.05–4.01]) as the only independent predictor of treatment for dislocation in the posterior group.Our analyses revealed that compromised patients with displaced FNFs who undergo arthroplasty via the posterior approach may report better symptoms at one-year vs. the anterolateral approach, despite a higher odds of reoperation for instability.

Treatment Failure After Repair of Displaced Femoral Neck Fractures in Patients Compared by "Decade of Life": An Analysis of 565 Cases in Adults Less Than 60 years of Age.

To study the results of displaced femoral neck fractures (FNFs) in adults less than 60 years of age by comparing patients, injury, treatment, and the characteristics of treatment failure specifically according to patients' age at injury, that is, by their "decade of life" [ie, "under 30" (29 years and younger), "the 30s" (30-39 years), "the 40s" (40-49 years), and "the 50s" (50-59 years)]. Multicenter retrospective comparative cohort series. Twenty-six North American Level 1 Trauma Centers. Skeletally mature patients aged 18-59 years with operative repair of displaced FNFs. Main outcome measures were treatment failures (fixation failure and/or nonunion, osteonecrosis, malunion, and the need for subsequent major reconstructive surgery (arthroplasty or proximal femoral osteotomy). These were compared across decades of adult life through middle age (<30 years, 30-39 years, 40-49 years, and 50-59 years). Overall, treatment failure was observed in 264 of 565 (47%) of all hips. The mean age was 42.2 years, 35.8% of patients were women, and the mean Pauwels angle was 53.8 degrees. Complications and the need for major secondary surgeries increased with each increasing decade of life assessed: 36% of failure occurred in patients <30 years of age, 40% in their 30s, 48% in their 40s, and 57% in their 50s (P < 0.001). Rates of osteonecrosis increased with decades of life (under 30s and 30s vs. 40s vs. 50s developed osteonecrosis in 10%, 10%, 20%, and 27% of hips, P < 0.001), while fixation failure and/or nonunion only increased by decade of life to a level of trend (P = 0.06). Reparative methods varied widely between decade-long age groups, including reduction type (open vs. closed, P < 0.001), reduction quality (P = 0.030), and construct type (cannulated screws vs. fixed angle devices, P = 0.024), while some variables evaluated did not change with age group. Displaced FNFs in young and middle-aged adults are a challenging clinical problem with a high rate of treatment failure. Major complications and the need for complex reconstructive surgery increased greatly by decade of life with the patients in their sixth decade experiencing osteonecrosis at the highest rate seen among patients in the decades studied. Interestingly, treatments provided to patients in their 50s were notably different than those provided to younger patient groups. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Effectiveness of fascia iliaca compartment block in adult fractured neck of femur patients: An integrative review

Effectiveness of fascia iliaca compartment block in adult fractured neck of femur patients: An integrative review

864 Optimizing Prescribing Strategies for Neck of Femur Fracture Patients: The Role of Electronic Order Sets

864 Optimizing Prescribing Strategies for Neck of Femur Fracture Patients: The Role of Electronic Order Sets

850 Streamlining Patient Care: Developing an Integrated Proforma for Neck of Femur Fracture Patients Across Multidisciplinary Teams

850 Streamlining Patient Care: Developing an Integrated Proforma for Neck of Femur Fracture Patients Across Multidisciplinary Teams

587 Preventing Post-Operative Orthostatic Hypotension in Orthogeriatric Neck of Femur Fracture Patients by Encouraging Oral Fluid Intake

587 Preventing Post-Operative Orthostatic Hypotension in Orthogeriatric Neck of Femur Fracture Patients by Encouraging Oral Fluid Intake

Efficacy and Safety of Orally and Intravenously Administration of Tranexamic Acid in Patients with Elderly Femoral Neck Fracture.

For elderly femoral neck fracture patients, anemia is one of the most common complications, increasing the risk of postoperative adverse events. Tranexamic acid (TXA) has been widely applied to the perioperative blood management. However, the optimal route of TXA administration in elderly femoral neck fracture remains unclear. The aim of this study is to evaluate the efficacy and safety of oral and intravenous (IV) application of TXA in elderly patients with femoral neck fracture undergoing total hip arthroplasty (THA) and hemiarthroplasty (HA). All elderly patients aged over 65 years old diagnosed with femoral neck fracture admitted to the trauma orthopedics from August 1, 2020 to February 28, 2022 were enrolled in this prospective cohort study. Participants were divided into three groups: oral group: TXA 2g orally 2 h before incision; IV group: intravenous infusion of TXA 1g 15 min before incision; and control group: usual hemostatic method. The primary outcomes were total blood loss, allogeneic transfusion rate, and postoperative thromboembolic events. SPSS 23.0 (IBM, Armonk, NY, USA) was used for statistical analysis, and p ≤ 0.05 was considered statistically significant. A total of 100 patients were enrolled, including 32 cases in the oral group, 34 cases in the IV group and 34 cases in the control group. Compared with the control group, the total perioperative blood loss in the oral and IV groups was significantly decreased (763.92 ± 358.64 mL vs 744.62 ± 306.88 mL vs 1250.60 ± 563.37 mL, p = 0.048). No significant difference was identified between the oral and IV groups (p = 0.970). The rate of allogeneic transfusion was lower in the oral and IV groups than in the control group, but the difference had no statistical significant (6 vs 5 vs 12, p = 0.108), However, subgroup analysis showed that the IV and oral groups in patients who underwent THA have significant lower transfusion rate compared with the control group (1 vs 3 vs 7, p = 0.02). During 6 months follow-up, no thromboembolic events were identified. Two patients (one from the oral group and one from the control group) died of respiratory failure. The cost of blood management from the oral group was significantly lower than IV (p < 0.001) and control groups (p = 0.009). Elderly patients with femoral neck fracture undergoing THA can benefit from both IV and oral administration of tranexamic acid. The results of these two administration routes are similar in safety and effectiveness. A similar tendency was observed in patients undergoing HA. Oral TXA is more cost-benefit compared with intravenous applications.

Equivalence in osteoporosis workup and management after femoral neck fracture fixation and vertebral compression fracture cement augmentation: A single-center retrospective study highlighting persistent underdiagnosis and undertreatment

BackgroundThe purpose of this study was to evaluate pre- and post-fracture medical management of osteoporosis among patients who underwent surgical fixation of femoral neck fractures (FNF) and vertebral compression fractures (VCF), and to investigate if there is a difference in treatment, management, and subsequent fractures between FNF and VCF patients. MethodsPatients who underwent surgical fixation of FNF or VCF were retrospectively reviewed at a minimum 1 year follow up. Patients were excluded if their fracture was caused by high energy trauma or malignancy, <50 years-old, deceased, or lost to follow up. Patient demographics such as age, sex, BMI, American Society of Anesthesiology Physical Status Classification System and Charleston Comorbidity index were recorded. Management of osteoporosis, including medication regimen and dual-energy X-ray absorptiometry (DEXA) scans were assessed preoperatively and at minimum one year follow up. Subsequent fractures were also recorded. ResultsIn the analysis of 370 patients (74.7% FNF, 25.2% VCF), demographics showed a predominantly female population (mean age 78.1). Preoperatively, 21.6% were diagnosed with osteoporosis, consistent between FNF and VCF. Postoperatively, there were no significant differences in new osteoporosis diagnoses, bisphosphonate use, or subsequent fractures. VCF patients, however, were more likely to receive denosumab and post-operative DEXA scans (p < 0.05). Within a year, 6.2% experienced subsequent fractures, with no significant FNF-VCF difference. Only 12.7% received appropriate post-operative osteoporosis treatment, 27.1% had DEXA scans, and 25% had a recorded osteoporosis diagnosis. Multivariable analysis highlighted pre-fracture osteoporosis diagnosis as the sole predictor for post-operative DEXA scans and anti-osteoporotic medication (p < 0.001). ConclusionsThis study suggests that factors beyond the type of fragility fracture may influence subsequent fracture risk and anti-osteoporotic medication administration in elderly patients. These findings underscore the importance of a comprehensive approach to fracture risk assessment and treatment decisions in this population. Level of evidenceIII.

Optimal Fixation Strategies for Displaced Femoral Neck Fractures in Patients 18-59 Years of Age: An Analysis of 565 Cases Treated at 26 Level 1 Trauma Centers.

The objective of this study was to determine the difference in failure rates of surgical repair for displaced femoral neck fractures in patients younger than 60 years of age according to fixation strategy. This is a retrospective, comparative cohort study. Twenty-six Level 1 North American trauma centers. Patients younger than 60 years of age with a displaced femoral neck fracture (OTA 31-B2, B3) undergoing surgical repair from 2005 to 2017. Patient demographics, injury characteristics, repair methods used, and treatment failure (nonunion/failed fixation, avascular necrosis, and need for secondary surgery) were compared according to fixation strategy. Five hundred and sixty-five patients met inclusion criteria and were studied. The mean age was 42 years, 36% were female, and the average Pauwels' angle of fractures was 55 degrees. There were 305 patients treated with multiple cannulated screws (MCS) and 260 treated with a fixed-angle (FA) construct. Treatment failures were 46% overall, but was more likely to occur in MCS constructs versus FA devices (55% vs. 36%, P < 0.001). When FA constructs were substratified, the use of a sliding hip screw with addition of a medial femoral neck buttress plate (FNBP) and "antirotation" (AR) screw demonstrated better results than either FNBP or AR screw alone or neither with the lowest overall construct failure rate of 11% (P < 0.036). Historically used fixation constructs for femoral neck fractures (eg, multiple cannulated screws and sliding hip screw) in young and middle-aged adults performed poorly compared with more recently proposed constructs, including those using a medial femoral neck buttress plate and an antirotation screw. Fixed-angle constructs outperformed multiple cannulated screws overall, and augmentation of fixed-angle constructs with a medial femoral neck buttress plate and antirotation screw improved the likelihood of successful treatment. Surgeons should prioritize fixation decisions when repairing displaced femoral neck fractures in patients. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Do Hypoalbuminaemia Increase the Risk of Surgical Site Infection in Neck of Femur Fracture Patients: A Systematic Review and Meta-Analysis.

Serum albumin plays an important role in physiological and inflammatory haemostasis, and low serum levels are linked with an increased incidence of surgical site infections (SSI). Although this has been demonstrated in the spine and elective arthroplasty settings, there is a paucity of evidence with regard to the effect of low serum albumin on rates of SSI following surgery for adult patients suffering from traumatic and acute hip fractures. A systematic review was conducted using the PRISMA guidelines. Four databases were searched for randomised controlled trials (RCTs), cohort studies, and case-controlled studies. The risk of bias was assessed using the Newcastle-Ottawa Score (NOS). Data was collected and pooled using RevMan Web software. Results were reported as odds ratios (OR) with 95% confidence intervals (CI) and statistical significance of p <0.05. An inverse variance model was used in the meta-analysis. Six retrospective studies (five cohorts and one case-control) with a total of 43,059 patients were included. 45.3% (n=19 496) had low serum albumin (<3.5 g/dL). Hypoalbuminemia was associated with a significantly higher risk of any form of SSI (OR 1.25, p=0.008) and deep SSI (OR 1.76, p=0.05). There was no statistical significance between hypoalbuminemia and the incidence of superficial SSI (OR 1.06, p=0.77). Organ-space SSI was associated with hypoalbuminemia, although one study reported this with poor statistical significance (OR 8.74, p<0.054). Hypoalbuminemia increases the risk of most forms of surgical site infections, both superficial and deep. There is a weak conclusion to draw between the incidence of deep-space organ infections and low serum albumin.

Contralateral Neck-shaft Angle Lower Than 130° Is Associated With Clinical Failure in Nongeriatric Individuals: Analysis of the National Femoral Neck Fracture Database of 1066 Patients.

Treatment of femoral neck fractures in patients who are nongeriatric (≤ 60 years) is challenging because of high failure rates. Anatomic parameters influence the biomechanical environment for fracture healing, but their associations with clinical prognosis remains unclear. (1) Which anatomic parameter that is identifiable on pelvic radiographs shows a statistical correlation with a higher risk of clinical failure defined as nonunion, avascular necrosis (AVN), reoperation, and functional failure (decrease in Harris hip score reaching the minimum clinically important difference) in the screw fixation of femoral neck fractures among nongeriatric patients? (2) How does the influence of anatomic parameters on clinical prognosis manifest: directly or mediated by additional mechanisms? This retrospective, multicenter study used a nationwide database in China. Between January 2014 and December 2020, we evaluated 1066 patients with femoral neck fractures with a median age of 53 years (interquartile range 46 to 56) and median follow-up period of 62 months. Anatomic parameters including femoral neck-shaft angle (NSA), femoral head radius, femoral neck width, femoral offset, acetabular center-edge angle, and acetabular sharp angle were variables of interest. The primary outcome was clinical failure including nonunion, AVN, reoperation, and functional failure (decrease in Harris hip score reaching the minimum clinically important difference). Risk factors for failure were first filtered using the Bayesian information criterion and then assessed with multiple regression adjusting for confounders. The mediation effect was further explored using model-based causal mediation analysis with a quasi-Bayesian Monte Carlo method. Of all anatomic parameters we assessed, the contralateral NSA was associated with clinical failure, after adjusting for all potential covariates and confounding variables (adjusted odds ratio 0.92 [95% confidence interval 0.89 to 0.95]; p < 0.001). The optimal threshold for the NSA was 130°, with the highest Youden index of 0.27. Patients with an NSA < 130° (41% [441 of 1066]) demonstrated an increased occurrence of nonunion (15% [68 of 441] versus 5% [33 of 625]; p < 0.001), AVN (32% [141 of 441] versus 22% [136 of 625]; p < 0.001), functional failure (25% [110 of 441] versus 15% [93 of 625]), and reoperations (28% [122 of 441] versus 13% [79 of 625]). The impact of an NSA less than 130° on clinical failure was direct and substantially mediated by the type of displaced fracture (mediation proportion: 18.7%). In our study of screw fixations for femoral neck fractures among nongeriatric patients, we identified that a contralateral NSA < 130° correlates with an increased risk of clinical failure including nonunion, AVN, functional failure, and reoperation. The effect is either direct or mediated through displaced fracture types. This is important for surgeons in order to recognize the elevated rate of clinical failure and nature of the challenging biomechanical environment, which should guide them in refining surgical details and selecting appropriate fixation and rehabilitation plans. Approaches to managing these fractures require further validation with large-scale clinical trials. Level III, prognostic study.

The IFT80/Hedgehog Pathway Regulates the Osteogenic-adipogenic Differentiation of Bone Marrow Mesenchymal Stem Cells.

Steroid-induced avascular necrosis of the femoral head (SANFH) is a typical refractory disease that often progresses irreversibly and has a high disability rate. Numerous studies have confirmed that abnormal osteogenic-adipogenic differentiation of bone marrow mesenchymal stem cells (BM-MSCs) is one of the major factors of SANFH. However, the mechanism remains to be elucidated. This study aimed to investigate the mechanism and effect of the IFT80/Hedgehog-mediated osteogenic-adipogenic differentiation of BM-MSCs in SANFH. Femoral head specimens of SANFH patients and femoral neck fractures (FNF) patients were collected to detect the expression of IFT80, Shh and osteogenic-adipogenic differentiation-related genes by immunohistochemistry (IHC), western blot (WB) and Reverse Transcription Quantitative Polymerase Chain Reaction (RT-qPCR). Based on the rabbit SANFH model, the mRNA expression and protein level of IFT80 and Shh were detected by RT-qPCR and WB. After the osteogenic/adipogenic differentiation based on rabbit BM-MSCs, the IFT80, Gli1, PPAR-γ, and Runx2 expression were detected. Differences in alkaline phosphodiesterase activity, calcium nodule, quantification/distribution of lipid droplets, expression of IFT80/Hedgehog axis, and the level of osteogenic- adipogenic associated factors were determined after IFT80 overexpression. RT-qPCR, WB and IHC revealed that IFT80 and Shh lowly expressed in the osteoblasts and intra-trabecular osteocytes at the edge of trabeculae and in the intercellular matrix of the bone marrow lumen in the SANFH specimens. The Runx2 expression was low, while the PPAR-γ expression was high in both human specimens and animal models of SANFH, suggesting that the balance of osteogenic-adipogenic differentiation was dysregulated. Rabbit BM-MSCs with stable overexpression of IFT80 showed increased alkaline phosphatase activity after induction of osteogenic differentiation, increased calcium nodule production, and decreased adipogenesis after induction of adipogenic differentiation. There is a dysregulation of the balance of osteogenic-adipogenic differentiation in SANFH. IFT80 may inhibit adipogenic differentiation while promoting osteogenic differentiation in rabbit BM-MSCs by activating the Hedgehog pathway.

Revision rate following unipolar versus bipolar hemiarthroplasty.

There has been much debate on use of bipolar or unipolar femoral heads in hemiarthroplasty for the treatment of femoral neck fractures. The outcome of these implants should be studied in the America Joint Replacement Registry (AJRR). All primary femoral neck fractures treated with hemiarthroplasty between January 2012 and June 2020 were searched in the AJRR. All cause-revision of unipolar and bipolar hemiarthroplasty and reasons for revision were assessed for these patients until June of 2023. There were no differences in number and reason for all cause revisions between unipolar and bipolar hemiarthroplasty (p = 0.41). Bipolar hemiarthroplasty had more revisons at 6 months postoperatively (p = 0.0281), but unipolar hemiarthroplasty had more revisions between 2 and 3 years (p = 0.0003), and after 3-years (p = 0.0085), as analysed with a Cox model. Patients with older age (HR = 0.999; 95% CI, 0.998-0.999; p = 0.0006) and higher Charlson Comorbidity Index (HR = 0.996; 95% CI, 0.992- 0.999; p = 0.0192) had a significant increase in revision risk. We suggest that surgeons should consider using bipolar prosthesis when performing hemiarthroplasty for femoral neck fracture in patients expected to live >2 years post injury.

Increasing the angle between caudal screw and the transverse plane may aggravate the risk of femoral head necrosis by deteriorating the fixation stability in patients with femoral neck fracture

Necrosis of the femoral head is the main complication in femoral neck fracture patients with triangle cannulated screw fixation. Instant postoperative fixation instability is a main reason for the higher risk of femoral head necrosis. Biomechanical studies have shown that cross screw fixation can effectively optimize fixation stability in patients with proximal humerus fractures and pedicle screw fixation, but whether this method can also effectively optimize the fixation stability of femoral neck fractures and reduce the corresponding risk of femoral head necrosis has yet to be identified. In this study, a retrospective review of imaging data in femoral neck fracture patients was performed. The cross angle between the femoral neck and the caudal cannulated screw was reported; if the angle between the screw and the transverse plane increased, it was recorded as positive; otherwise, it was recorded as negative. Angle values and their corresponding absolute values were compared in patients with and without femoral head necrosis. Regression analysis identified potential risk factors for femoral head necrosis. Moreover, the biomechanical effect of the screw–femoral neck angle on fixation stability was also verified by numerical mechanical simulations. Clinical review presented significantly larger positive angle values in patients with femoral head necrosis, which was also proven to be an independent risk factor for this complication. Moreover, fixation stability progressively deteriorated with increasing angle between the caudal screw and the transverse plane. Therefore, increasing the angle between the caudal screw and the transverse plane may aggravate the risk of femoral head necrosis by deteriorating the fixation stability in patients with femoral neck fracture.