Transcervical Fractures Research Articles

Proximal hip fractures in 71,920 elderly patients: incidence, epidemiology, mortality and costs from a retrospective observational study

BackgroundThe risk of proximal femoral fractures increases with aging, causing significant morbidity, disability, mortality and socioeconomic pressure. The aims of the present work are (1) to investigate the epidemiology and incidence of these fractures among the elderly in the Region of Lombardy; (2) to identify the factors influencing survival; (3) to identify the factors influencing hospitalization and post-operative costs.MethodsThe Region of Lombardy provided anonymized datasets on hospitalized patients with a femoral neck fracture between 2011 and 2016, and anonymized datasets on extra-hospital treatments to track the patient history between 2008 and 2019. Statistical evaluations included descriptive statistics, survival analysis, Cox regression and multiple linear models.Results71,920 older adults suffered a femoral fracture in Lombardy between 2011 and 2016. 76.3% of patients were females and the median age was 84. The raw incidence of fractures was stable from year 2011 to year 2016, while the age-adjusted incidence diminished. Pertrochanteric fractures were more spread than transcervical fractures. In patients treated with surgery, receiving treatment within 48 h reduced the hazard of death within the next 24 months. Combined surgical procedures led to increased hazard in comparison with arthroplasty alone, while no differences were observed between different arthroplasties and reduction or fixation. In patients treated conservatively, age and male gender were associated with higher hazard of death. All patients considered, the type of surgery was the main factor determining primary hospitalization costs. A higher number of surgeries performed by the index hospital in the previous year was associated with financial savings. The early intervention significantly correlated with minor costs.ConclusionsThe number of proximal femoral fractures is increasing even if the age-adjusted incidence is decreasing. This is possibly due to prevention policies focused on the oldest cohort of the population. Two policies proved to be significantly beneficial in clinical and financial terms: the centralization of patients in high-volume hospitals and a time limit of 48 h from fracture to surgery.Trial registrationNon applicable.

Revision total hip prosthesis with a primary prosthesis without bone graft

The durability of total hip prostheses and changes in surgical approaches for femoral neck fractures is a crucial issue in the medical literature. Worldwide, it has been observed that the longevity of total hip prostheses ranges from 10 to 30 years, according to several studies. This phenomenon could be due to several factors, such as differences in population demographics, variations in standards of care, or even particularities in the health and lifestyle of local patients. A 56-year-old male patient, with a history of electrocution in 2000 in which he suffered a transcervical fracture of the left hip with traumatic amputation of the right forearm; a total left hip arthroplasty with polyethylene metal head 28 was performed. It is concluded that, the clinical case highlights the need for individualized care and an adaptive approach in the management of total hip replacements, underlining that a careful approach and execution of preoperative, intraoperative and postoperative plans can lead to satisfactory and durable results, even in rare situations.

Short-Term Outcomes of Uncemented Bipolar Hemiarthroplasty Using Stainless Steel Fully Hydroxyapatite-Coated Stem in Transcervical Fracture of the Femur.

Bipolar hemiarthroplasty is the standard of care for transcervical fracture in the elderly. Stainless steel being cheaper is preferred over titanium in developing nations for implants and prostheses. This study was conducted for assessing the short-term outcomes of uncemented bipolar hemiarthroplasty done using hydroxyapatite-coated stainless steel prosthesis. Sixty-five patients, >60year of age operated between 2018 and 2020 at tertiary care centre with stainless steel (316L) completely coated with hydroxyapatite bipolar hemiarthroplasty implants were retrospectively followed up. Radiological outcomes were assessed based on pedestal formation, stem position, radiological limb length discrepancy, sinkage of stem, spot welds and stress shielding. Clinical and functional outcomes were assessed based on mean Harris Hip score. Mean Harris Hip score at baseline, 3-week follow-up, 6-week follow-up, 3-month follow-up and 1-year follow-up was 45.9 (SD 2.5), 63.2 (SD 6.5), 75.1 (SD 9.9), 83.9 (SD 9.8) and 87.1 (SD 9.9), respectively. Excellent, good, fair, poor results were seen in 32.31, 40, 18.46, 9.23 of the patients, respectively. Valgus, central and varus stem position was seen in 49.23, 40, 10.77 percent of the patients, respectively. Pedestal formation, radiological limb length discrepancy, sinkage, spot welds, stress shielding was seen in 6.15, 32.31, 3.07, 53.85, 40 percent of the patients, respectively. Short-term outcomes of this study provides evidence that using a more affordable fully hydroxyapatite-coated stainless steel prosthesis for uncemented bipolar hemiarthroplasty is an appropriate treatment option for the transcervical femur fracture.

Optimal drilling at femoral head-neck junction for treatment of the femoral head necrosis: Experimental and numerical evaluation

Advanced core decompression (ACD) is a relative new technique for treatment of early stages of avascular femoral head necrosis. Although it is a promising treatment option, there is a need to modify this technique for achieving higher hip survival rates. An idea was to combine this technique with the lightbulb procedure in order to get a complete removal of the necrosis. This study aimed at evaluating the fracture risk of the femora treated by the combined Lightbulb-ACD technique as the basis for clinical application. Subject-specific models were generated from CT scan data of five intact femora. Several treated models were then created from each intact bone and simulated during normal walking activity. Biomechanical testing was additionally performed on 12 pairs of cadaver femora to confirm the simulation results. The finite element results revealed that the risk factor of the treated models with a 8mm-drill increased, but was not significantly greater than that of their corresponding intact models. However, for the femur treated with a 10mm-drill, the risk factor increased significantly. Fracture always initiated on the femoral neck, i.e. it was either subcapital or transcervical fracture. Our biomechanical testing results correlated well with the simulation data which confirmed the usefulness and effectiveness of the bone models. The combined Lightbulb-ACD technique using a 10mm drill increased the fracture risk of femur postoperatively. A drill of up to 8mm at the anterior head-neck junction did not however lead to the weakening of the femur so that full load bearing may be possible.

Outcomes of Closed Reduction and Internal Fixation (CRIF) by Cannulated Cancellous Hip Screw in Transcervical Fracture Neck of Femur in Children

Introduction: Fracture of the neck of the femur is one of the most common and difficult problems all over the world, for all ages. As the femur is the weight-bearing bone in the lower limbs, fracture of the neck femur creates severe problems like shortening, limping, and a painful unstable hip. The incidence of pediatric neck fractures is highest in children above the age of eleven. The most common cause is high-energy trauma such as motor vehicle accidents and falls from height, also osteogenesis imperfecta, and myelomeningocele. This study aimed to analyze the outcomes of closed reduction and internal fixation (CRIF) by the cannulated cancellous hip screw in the transcervical fracture neck of the femur in children. Methods: This prospective interventional study was conducted at the National Institute of Traumatology & Orthopedic Rehabilitation (NITOR), Dhaka, from July 2011 to June 2013. A total of 16 patients were selected for this study as per inclusion criteria. All statistical analysis of different variables was analyzed according to the standard statistical method by using SPSS. Result: In this study, the age of the patients ranged from 5-18 years with an average age of 11.25 years. The majority of the patients (56.25%) belonged to the age group 10-14 years, followed by 31.25% in the age group 5-9 years, and the rest 12.50% in the 15-18 years age group. Out of 16 patients, 10 patients (62.50%) were male and 06 patients (37.50%) were female. In the present study, the anatomical reduction was achieved in 07 (43.75%), the acceptable reduction was achieved in 05 (31.25%), and the unacceptable reduction in 04 (25.0%). The average time interval between injury and operation was 7.3 days, out of 16 study cases, 10 cases operated within 7 days of which 9 were united (90.0%), and 6 cases were operated after 7 days, of which 4 (66.66%) were united. Out of 16 patients, 12 (75.0%) regained full range of hip movement and 04 (25.0%) patients had limited range of motion. ...

Locking Plate Versus Cannulated Screws in The Management of Transcervical Fracture Neck Femur

Locking Plate Versus Cannulated Screws in The Management of Transcervical Fracture Neck Femur

Clinical case of applying a safe loading range to a limb in a patient with a femoral neck fracture

Introduction. Currently, most orthopedic traumatologists consider surgical treatment as the method of choice for fractures of the femoral neck. However, despite the constant modernization of the available methods of osteosynthesis, the proportion of unsatisfactory outcomes of surgical intervention and the occurrence of early postoperative complications remains quite high (from 28 to 45%) [1]. One of the main directions for solving the problem of unsatisfactory outcomes of osteosynthesis is the improvement and strict control of measures taken in the postoperative period, including early activation of the patient. Despite the importance of the recovery period, there are still no unified standards for managing patients with hip fractures, and the available treatment protocols contain only a generalized plan for further therapeutic measures that do not take into account the individual characteristics of the patient. We have proposed a method for calculating the optimal load on the limb in the postoperative period. The purpose of this publication is to describe a clinical case of the effective application of the method for determining the optimal range of loads on a limb after surgical treatment of femoral neck fractures.Materials and methods: the study used materials from medical records and instrumental studies of the traumatology department of the TOGBUZ "City Clinical Hospital of Kotovsk", the results of dynamic observation for 12 months in a patient with a transcervical fracture of the femoral neck, for which the method we developed for determining the optimal range was applied. load on the limb after surgical treatment of injury.Results: 12 months after the operation, the patient who used the method for determining the safe load range in the recovery period achieved full functional and anatomical recovery of the operated limb. Full body weight bearing was allowed from the 6th month.Conclusion: the method for determining the safe range of load on the limb after a femoral neck fracture has been tested in practice and led to a positive result, which may indicate its effectiveness.

Predicting the Anatomical Location of Neck of Femur Fractures in Osteoporotic Geriatric Indian Population.

Introduction:Neck of femur fractures are quite common fractures in the elderly. Though a lot is spoken about the various modes of management of these fractures across different age groups, hardly any literary support mentioning their distribution, location and pattern can be found. In this study, we aim to find whether the Singh index, as a marker of osteoporosis on digital radiographs, can predict the location of neck of femur fractures in the elderly population.Materials and methods:We accessed 556 fractured hip radiographs in our institution over the past 5 years (20152020) and correlated with the Singh index, as a marker of degree of osteoporosis, on pre-operative pelvis digital radiographs. Mid coronal CT cuts were also corroborated with the radiographic findings. A control group was set up and 361 radiographs were evaluated in the study group.Results:A total of 124 transcervical fractures (73%) were in Singh index 4, while 76 subcapital fractures (70%) were in Singh index 3. A total of 166 fractures (66%) were found in transcervical region in the age group of 60 to 80 years, while 80 fractures (74%) were in the subcapital region in patients above 80 years.Conclusion:We concluded that transcervical fractures were more common in patients with Singh index 4 (p<0.001) and subcapital more common in patients with Singh index 3(p<0.001). There was also a shift in location of the fractures from the transcervical region to the subcapital region with age above 80 years (p<0.001).

Functional Outcome Of Delayed Presenting Fracture Neck Of Femur Managed By Cannulated Screw And Fibular Graft.

Delayed presenting Fracture neck of femur is one of the complex and challenging fracture to treat. Multiple treatment options are available with varying results. This study was conducted to assess the functional outcome of fracture neck of femur seeking medical attention several days after injury that are managed by cannulated screw and fibular. A total of 35 patients were included in the cross-sectional study performed at orthopaedic surgery department of United Medical & dental college Karachi. Adults aged 18 years and over both male and female with fracture neck of femur presenting 14 days after the injury for medical treatment were included in the study. Ethical approval was obtained from the ethical review committee and patients who provided written informed consent were included in study. Data analysis was performed through SPSS version 20. Thirty-five patients with fracture neck of femur of both sexes 25 (71.4%) male and 10 (28.6%) females were included in study. out of which 14 (40%) of the patients had sub-capital fracture and 21 (60%) patients had trans-cervical fracture neck of femur. Mean age of patients was 32.14±10.20 years. Twenty-eight (80%) patients out of 35 had excellent and good outcome, 4 (11.4%) cases had fair and 3 (8.5%) had poor outcome. Cannulated screw fixation along with non-vascularized fibular graft is effective technique to management of delayed presenting fracture neck of femur as it is easy, inexpensive and does not require any special instrumentation or expertise.

Smith-Petersen Versus Watson-Jones Approach Does Not Affect Quality of Open Reduction of Femoral Neck Fracture.

To compare immediate quality of open reduction of femoral neck fractures by alternative surgical approaches. Retrospective cohort study. Twelve Level 1 North American trauma centers. Eighty adults 18-65 years of age with isolated, displaced, OTA/AO type 31-B2 or -B3 femoral neck fractures treated with internal fixation. Thirty-two modified Smith-Petersen anterior approaches versus 48 Watson-Jones anterolateral approaches for open reduction performed by fellowship-trained orthopaedic trauma surgeons. Reduction quality as assessed by 3 senior orthopaedic traumatologists as "acceptable" or "unacceptable" on AP and lateral postoperative radiographs. No difference was observed in the rate of acceptable reduction by modified Smith-Petersen (81%) versus Watson-Jones (81%) approach (risk difference null, 95% confidence interval -17.4% to 17.4%, P = 1.00) with 90.4% panel agreement (Fleiss' weighted κ = 0.63, P < 0.01). Stratified analyses did not identify a significant difference in the rate of acceptable reduction between approaches when stratified by Pauwels angle, basicervical or transcervical fracture location, or posterior comminution. The Smith-Petersen approach afforded a better reduction when preoperative skeletal traction was not applied (RR = 1.67 [95% CI 1.10-2.52] vs. RR = 0.87 [95% CI 0.70-1.08], P = 0.006). No difference was observed in the quality of open reduction of displaced femoral neck fractures in young adults when a Watson-Jones anterolateral approach versus a modified Smith-Petersen anterior approach was performed by orthopaedic trauma surgeons. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Factors Associated with Recovered Functionality After Hip Fracture in Non-Institutionalized Older Adults: A Case-Control Study Nested in a Cohort

PurposeTo identify factors associated with recovered functionality after a hip fracture in a sample of older adult patients.Patients and MethodsNested case-control study in a cohort. Older adults (60 years or older) with a hip fracture were recruited between May 2017 and October 2018. The Barthel scale was used to measure performance in activities of daily living (ADL). A questionnaire was applied to collect information about demographic, clinic, psychological and social variables, and anthropometric measurements were taken. A logistic regression model was built to analyze various factors related to recovered functionality.ResultsA total of 346 older adults with a hip fracture were studied (n=173 cases and n=173 controls); 69.4% (n=240) women and 30.6% (n=140) men. Mean age was 79.4 years (±8.7) overall; for cases, 77.4 (±7.9) years and for controls, 81.4 (±9.0). Mean schooling was 6.3 (± 4.3) years. Recovered functionality was associated with normal nutritional status (OR 4.81, 95% CI = 2.54–9.12), absence of heart disease (OR 4.08, 95% CI = 1.48–11.20), self-efficacy for ADL (OR 4.07, 95% CI = 2.15–7.72), absence of depressive symptoms (OR 2.99, 95% CI = 1.69–5.28), prior functionality (OR 2.83, 95% CI = 1.51–5.31), high socioeconomic level (OR 2.41, 95% CI = 1.24–4.65) and transcervical fracture (OR 2.34, 95% CI = 1.05–5.22).ConclusionIn older adults who have suffered a hip fracture, clinical, psychological, and demographic characteristics are associated with recovered functionality. These factors should be considered as a priority in the care of older adults who have experienced hip fractures.

Single lag screw and reverse distal femur locking compression plate for concurrent cervicotrochanteric and shaft fractures of the femur: biomechanical study validated with a clinical series.

The optimal surgical management of concurrent cervicotrochanteric and shaft fractures of the femur has not been consensual. The authors investigated the reliability of combined single lag screw and reverse distal femur locking compression plate (LCP-DF) by finite element (FE) study and retrospectively described the present technique for these dual fractures. Intact femurs were derived from CT data, and the implant models were created by using CAD software. The fractured femur and implant models were virtually aligned based on the surgical techniques before converting to the FE model. In the FE model, applied boundary conditions included body weight, muscle forces, and constraint of the joints. Regarding clinical series, three patients with these dual fractures of the femur and 2 with cervicotrochanteric fractures with subtrochanteric extension were operated on by the proposed technique. The collected data include operative time, postoperative complications, union times, and clinical outcomes. Equivalent von Mises stress exhibited on dynamic hip screws with an anti-rotational screw was higher than the other techniques, close to the yield stress of the material. Multiple screw fixation produced better stability for transcervical fractures whereas the proposed technique of combined single lag screw and reverse LCP-DF provided better stability for intertrochanteric fractures. No significant difference in cortical bone stress was found between multiple screw construct and the proposed technique. The proposed technique presented a lower risk of secondary fractures, as the strain energy density (SED) in cancellous bone was lower than multiple screw construct. Regarding clinical series, all fractures were united with a mean union time of-16.1weeks (range 12-20). There were no any postoperative complications. Regarding the Harris score, 1 was determined to be excellent value, and 4 to be good. By the FE results, a combination of a single lag screw and reverse LCP-DF is an effective technique for fixation of cervicotrochanteric fractures. Empowered by the clinical results, this proposed technique could be an alternative for concurrent cervicotrochanteric and shaft fractures of the femur especially when either single-system or dual-system devices seem not to be suitable.

Experience with the use of bioactive calcium phosphate-coated implants in multicomponent traumatic damage to the hip joint

Objective. To study the effectiveness of using implants with a bioactive calcium-phosphate coating on the example of treating a patient with combined fractures of the acetabulum and the neck of the femur.&#x0D; Materials and methods. A 52-year-old patient, injured as a result of a traffic accident with multicomponent damage to the right hip joint (transcervical fracture of the femoral neck and a high two-column fracture of the acetabulum). Osteosynthesis of the femoral neck fracture is made by three cannulated screws with a calcium-phosphate coating (patent of the RU No. 81427). For the osteosynthesis of the acetabular fracture, a reconstructive plate with a calcium-phosphate coating was used (patent of the RU No. 113945).&#x0D; Results. Despite the heavy, multi-component destruction of the hip joint, consolidation of the fractures ensued. The remote result is tracked for 10 years. On the score scale of the functional results Harris 89 points, the result is rated as good.&#x0D; The conclusion. The use of imantates with bioactive calcium-phosphate coatings from hydroxyapatite promotes activation of reparative processes in the region of fractures.

Open Reduction Is Associated With Greater Hazard of Early Reoperation After Internal Fixation of Displaced Femoral Neck Fractures in Adults 18-65 Years.

To determine (1) which factors are associated with the choice to perform an open reduction and (2) by adjusting for these factors, if the choice of reduction method is associated with reoperation. Retrospective cohort study with radiograph and chart review. Twelve Level 1 North American trauma centers. Two hundred thirty-four adults 18-65 years of age with an isolated, displaced, OTA/AO type 31-B2 or type 31-B3 femoral neck fracture treated with internal fixation with minimum of 6-month follow-up or reoperation. Exclusion criteria were pathologic fractures, associated femoral head or shaft fractures, and primary arthroplasty. Open or closed reduction technique during internal fixation. Cox proportional hazard of reoperation adjusting for propensity score for open reduction based on injury, demographic, and medical factors. Reduction quality was assessed by 3 senior orthopaedic traumatologists as "acceptable" or "unacceptable" on AP and lateral postoperative radiographs. Median follow-up was 1.5 years. One hundred six (45%) patients underwent open reduction. Reduction quality was not significantly affected by open versus closed approach (71% vs. 69% acceptable, P = 0.378). The propensity to receive an open reduction was associated with study center; younger age; male sex; no history of injection drug use, osteoporosis, or cerebrovascular disease; transcervical fracture location; posterior fracture comminution; and surgery within 12 hours. A total of 35 (33%) versus 28 (22%) reoperations occurred after open versus closed reduction (P = 0.056). Open reduction was associated with a 2.4-fold greater propensity-adjusted hazard of reoperation (95% confidence interval 1.3-4.4, P = 0.004). A total of 35 (15%) patients underwent subsequent total hip arthroplasty or hemiarthroplasty. Open reduction of displaced femoral neck fractures in nonelderly adults is associated with a greater hazard of reoperation without significantly improving reduction. Prospective randomized trials are indicated to confirm a causative effect of open versus closed reduction on outcomes after femoral neck fracture. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Association between osteoporotic femoral neck fractures and DXA-derived 3D measurements at lumbar spine: a case-control study.

The aim of the present study was to evaluate the association between DXA-derived 3D measurements at lumbar spine and osteoporotic hip fractures. We analyzed a case-control database composed by 61 women with transcervical hip fractures and 61 age-matched women without any type of fracture. DXA scans at lumbar spine were acquired, and areal bone mineral density (aBMD) was measured. Integral, trabecular and cortical volumetric BMD (vBMD), cortical thickness, and cortical surface BMD (sBMD) at different regions of interest were assessed using a DXA-based 3D modeling software. Descriptive statistics, tests of difference, odds ratio (OR), and area under the receiver operating curve (AUC) were used to compare hip fracture and control groups. Integral vBMD, cortical vBMD, cortical sBMD, and cortical thickness were the DXA-derived 3D measurements at lumbar spine that showed the stronger association with transcervical hip fractures, with AUCs in the range of 0.685-0.726, against 0.670 for aBMD. The highest AUC (0.726) and OR (2.610) at the lumbar spine were found for integral vBMD at the posterior vertebral elements. Significantly, lower AUC (0.617) and OR (1.607) were found for trabecular vBMD at the vertebral body. Overall, total femur aBMD remains the DXA-derived measurement showing the highest AUC (0.838) and OR (6.240). This study showed the association of DXA-derived measurements at lumbar spine with transcervical hip fractures. A strong association between vBMD at the posterior vertebral elements and transcervical hip fractures was observed, probably because of global deterioration of the cortical bone. Further studies should be carried out to investigate on the relative risk of transcervical fracture in patients with long-term cortical structural deterioration.

Management of Low-Energy Basicervical Proximal Femoral Fractures by Proximal Femoral Nail Anti-Rotation.

ObjectiveTo evaluate clinical and radiological outcomes of proximal femoral nail anti‐rotation (PFNA‐II) devices and demonstrate the effectiveness of PFNA‐II for the treatment of basicervical fractures in elderly patients.MethodsA retrospective review of all patients treated with PFNA‐II for a proximal femoral fracture between January 2013 and February 2017 at three different institutions (Shanghai General Hospital, Shanghai Punan Hospital and Shanghai Seventh People's Hospital) was conducted. The X‐ray films were strictly reviewed by three trauma surgeons and a professional radiology doctor. Patients over 60 years of age who met the following criteria were included: (i) sustained low‐energy trauma; (ii) a two‐part fracture; (iii) fracture line located at the base of the femoral neck and that was medial to the intertrochanteric line and exited above the lesser trochanter but was more lateral than a classic transcervical fracture. Follow‐up time should be longer than 6 months. A total of 52 patients who met the inclusion criteria were selected. The average age at diagnosis was 75.1 years (range, 63–91 years); 13 patients were men and 39 were women. The same proximal femoral nail anti‐rotation devices and the same surgical procedures were applied to all patients. Postoperative radiographic union time and modified Harris hip scores were used as major indicators for evaluating the effectiveness of surgery.ResultsThe average follow‐up period was 22.5 months (18.5, 23.9, and 21.2 months, respectively) and radiographic unions were observed at an average of 19.6 weeks (range, 12–28 weeks). The patients were evaluated immediately after surgery, as well as 6 weeks, 3 months, 6 months, 1 year, and 2 years postoperatively. Of the 49 patients, 38 had good reduction qualities (75.5%), 9 acceptable (18.3%), and 3 poor (6.1%). Radiographic union was confirmed in all fractures at an average of 19.6 weeks (range, 12–28 weeks). The mean Harris hip score was 84.9 (range, 65–99): excellent in 9 patients (18.36%), good in 30 (61.22%), medium in 8 (16.32%), and poor in 2 (4.08%). Slight persistent pain occurred in 3 patients, but these patients could still walk with the help of a cane. Two patients had symptoms of excessive telescoping. Eight patients experienced postoperative medical complications, mainly pneumonia and urinary tract infection.ConclusionBased on the clinical and radiological outcomes, the PFNA‐II devices provide strong rotational stability and excellent clinical prognosis, and are an appropriate treatment option for basicervical proximal femoral fracture in elderly patients.

Management of transcervical and basicervical fracture of neck femur with DHS &amp; derotation screw - A prospective study

Management of transcervical and basicervical fracture of neck femur with DHS &amp; derotation screw - A prospective study

Biomechanics of Femoral Neck Fractures and Implications for Fixation.

Fractures of the femoral neck can occur in young healthy individuals due to high loads occurring during motor vehicle accidents, impacts, or falls. Failure forces are lower if impacts occur sideways onto the greater trochanter as compared with vertical loading of the hip. Bone density, bone geometry, and thickness of cortical bone at the femoral neck contribute to its mechanical strength. Femoral neck fractures in young adults require accurate reduction and stable internal fixation. The available techniques for fracture fixation at the femoral neck (cannulated screws, hip screw systems, proximal femur plates, and cephallomedullary nails) are reviewed with respect to their competence to provide biomechanical stability. Mechanically unstable fractures require a load-bearing implant, such as hip screws, with antirotational screws or intramedullary nails. Subcapital or transcervical fracture patterns and noncomminuted fractures enable load sharing and can be securely fixed with cannulated screws or solitary hip screw systems without compromising fixation stability.

Femoral neck cortical bone in female and male hip fracture cases: Differential contrasts in cortical width and sub-periosteal porosity in 112 cases and controls.

To quantitate differences between cases of hip fracture and controls in cortical width around the mid-femoral neck in men and women. Over 5 years, 64 (14 male) participants over age 55 (mean 79) years, who had never taken bone-active drugs and suffered intra-capsular hip fracture treated by arthroplasty, donated their routinely discarded distal intra-capsular femoral neck bone for histomorphometry. After embedding, complete femoral neck cross sections from the cut surface near the narrowest part of the neck were stained with von Kossa and cortical width was measured radially every 5 degrees of arc. Control material (n = 48, 25 male) was available through consented post mortems prior to the year 2000. Cortical widths were averaged for circumferential octants, each representing 45 degrees of arc. Divergence of individual cortical widths from their means was also examined. Because sections were required to have a complete cortex, sampling was biased towards cases with sub-capital versus trans-cervical fractures. Compared to sex- and age matched controls, male cases showed larger relative differences in cortical widths than female cases. Unexpectedly, cortical widths in female but not male cases also showed marked over-representation of extremely narrow (<0.1 mm) cortical widths, located mainly posteriorly. The numbers of these very narrow cortical widths observed per subject retrospectively predicted female fracture status in logistic regression independently of mean cortical width values. Together with mean cortical width differences, the numbers of measured cortical widths <0.1 mm (out of 72 measured) raised the sensitivity of predicting fracture status in women from 48 to 80% at 80% specificity. In almost all cases, very narrow cortical widths were identified in regions enclosing a cortical pore roofed on its endosteal surface by thin structural bone defined a priori as trabecular. Cortical widths <0.1 mm probably reflect zones where endosteal cortex has been trabecularised through expansion of an un-refilled sub-endosteal canal close to the periosteum. Persistent cortical defects occurring near the periosteal surface, where mechanical loading exerts its greatest stresses, are likely to result in extremes of localized concentrations of stress during a fall, unknown in young normal fallers. Such defects have the potential to help explain the excess of hip fractures among elderly women. Prevention of sub-periosteal tunnelling by osteoclasts might explain in part the additional benefits, beyond an increase in bone density, of treatments that reduce excessive bone resorption or else stimulate new bone formation on previously resorbed surfaces.

Classifications in Brief: Garden Classification of Femoral Neck Fractures.

Classifications in Brief: Garden Classification of Femoral Neck Fractures.