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Sadeghpour A, Mahdipour S, Ghanjpour Sales J, Aslani H, Moharrami MR, Alizadeh H. Non-cannulated versus cannulated cancellous screws for the internal fixation of femoral neck fractures in osteoporotic patients: A single-blind randomized clinical trial. J Orthop 2024; 51:32-38. [PMID: 38299065 PMCID: PMC10825919 DOI: 10.1016/j.jor.2023.11.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 11/26/2023] [Accepted: 11/28/2023] [Indexed: 02/02/2024] Open
Abstract
Background The incidence of femoral neck fractures in osteoporotic patients is rising worldwide and is associated with significant increases in healthcare and social costs, as well as dependency. Improving minimally invasive treatment strategies, including internal fixation with screws, can result in favorable clinical outcomes and lesser incidence of complications, while preserving the hip. This study compared the outcomes of using non-cannulated cancellous screws (NCS) and cannulated cancellous screws (CS) in the internal fixation of undisplaced intracapsular femoral neck fractures (UIFNF) of osteoporotic patients of Iranian descent. Methods This randomized clinical trial was conducted on the patients referring to an institutional tertiary hospital in northwestern Iran between March 2020 and June 2021. The patients' preoperative, perioperative, and postoperative characteristics were evaluated for at least two years. Primary endpoints were defined as the incidence of hip-related complications, while secondary endpoints were assessed based on the patients' hip function using Harris Hip Score (HHS). Results Fifty-seven patients with osteoporosis and UIFNF were included in the final analysis, with 27 patients in the NCS group and 30 patients in the CS group. The surgical duration, the amount of intraoperative blood loss, and the frequency of C-arm were considerably lower in the CS group (p < 0.05). The incidence of implant failure was higher in the NCS group (p = 0.04). Screw migration occurred more frequently in the CS group (p = 0.03). The HHS values were significantly higher for the NCS group than those of the CS group at both the 1-year and 2-years of follow-up assessments (1 year, p = 0.007; 2 years, p = 0.001). Conclusion Fixation using CS was accompanied by enhanced perioperative outcomes and lower implant failure rates compared to the NCS group. However, patients in the NCS group posed a reduced risk of complications, including screw migration, and experienced a long-term improvement in HHS scores.
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Affiliation(s)
- Alireza Sadeghpour
- Department of Orthopedic Surgery, Shohada Educational Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Shahab Mahdipour
- Department of Orthopedic Surgery, Shohada Educational Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Jafar Ghanjpour Sales
- Department of Orthopedic Surgery, Shohada Educational Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hossein Aslani
- Department of Orthopedic Surgery, Shohada Educational Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mohammad Reza Moharrami
- Department of Orthopedic Surgery, Shohada Educational Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hadi Alizadeh
- Department of Orthopedic Surgery, Shohada Educational Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Fan ZY, Shu LY, Jin YZ, Sherrier MC, Yin BH, Liu CJ, Zhan S, Sun H, Zhang W. Biomechanical evaluation of compression buttress screw and medial plate fixation for the treatment of vertical femoral neck fractures. Injury 2022; 53:3887-3893. [PMID: 36195517 DOI: 10.1016/j.injury.2022.09.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 09/25/2022] [Accepted: 09/26/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare the biomechanical properties of compression buttress screw (CBS) fixation with three plate fixation methods for the treatment of vertical femoral neck fractures (FNFs). METHODS A total of forty synthetic femoral models with simulated Pauwels type III fractures (angle of 70°) were equally assigned to one of four fixation groups: CBS fixation, anteromedial plate fixation (AMP), medial buttress plate fixation (MBP) and medial buttress plate fixation without proximal screw (MBPw). Within each group, half of the specimens were randomly assigned to two loading settings, an axial compression loading test and a hip-flexion torsion test. RESULTS There were no significant differences in axial load to failure, axial stiffness, torsional strength, or torsional stiffness when comparing CBS with MBP (p>0.05). In the axial compression loading test, both CBS and MBP showed higher load to failure and axial stiffness than MBPw (p<0.05). In torsional testing, AMP exhibited superior torsional strength and torsional stiffness than both MBPw and MBP (all p<0.05) and a higher torsional strength than CBS fixation (p<0.05). There were no significant differences in torsional stiffness between the CBS and AMP fixation groups (p>0.05). CONCLUSION The biomechanical parameters of CBS fixation are comparable to that of AMP and MBP, and demonstrate superior axial stiffness than MBPw fixation. Although the CBS method for surgical fixation of vertical FNF holds promise as a less invasive surgical technique than plate fixation with similar biomechanical assessments, further clinical evaluation is warranted.
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Affiliation(s)
- Zhi-Yuan Fan
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 YiShan Road, Shanghai 200233, China
| | - Lin-Yuan Shu
- Department of Emergency Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 YiShan Road, Shanghai 200233, China
| | - Ying-Zhe Jin
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 YiShan Road, Shanghai 200233, China
| | - Matthew C Sherrier
- Department of Orthopaedic and Physical Medicine, Medical University of South Carolina, Charleston, SC, 29425, United States of America
| | - Bo-Hao Yin
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 YiShan Road, Shanghai 200233, China
| | - Chen-Jun Liu
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 YiShan Road, Shanghai 200233, China
| | - Shi Zhan
- Orthopaedic Biomechanical Laboratory, Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 YiShan Road, Shanghai 200233, China
| | - Hui Sun
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 YiShan Road, Shanghai 200233, China.
| | - Wei Zhang
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 YiShan Road, Shanghai 200233, China.
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Li J, Yin P, Li J, Zhao Z, Zhao J, Cui X, Lyu H, Zhang L, Tang P. Novel slide compression anatomic plates of the femoral neck for treating unstable femoral neck fracture: A biomechanical study. J Orthop Res 2022; 41:1088-1096. [PMID: 36116025 DOI: 10.1002/jor.25447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 08/01/2022] [Accepted: 09/14/2022] [Indexed: 02/04/2023]
Abstract
To compare the biomechanical stability of slide compression anatomic plates of the femoral neck, cannulated compression screws and dynamic hip screws with derotation screws for stabilizing unstable femoral neck fractures (Pauwels angle = 70°). Pauwels III femoral neck fractures were created on 45 Sawbones femurs and randomly assigned to three implant groups (1:1:1). The biomechanical stability of all Sawbones in each treatment group was evaluated with three tests. First, in the static loading test, the load-displacement curve, vertical stiffness (load/vertical displacement [N/mm]) and 5 mm failure load were recorded. Second, in the incremental cyclic loading test (700, 1000, and 1400 N), the cyclic-displacement curve and the displacement of the fragments were recorded. Third, in the torsion test, the torsional rigidity, maximum torque, and torsional angle corresponding to the maximum torque were recorded. The static compression test showed that slide compression anatomic place-femoral neck (SCAP-FN) had the largest vertical stiffness (275 ± 11 N/mm, p < 0.01) and 5 mm failure load (1232 ± 156, p < 0.01). The cyclic loading test showed that SCAP-FN had the lowest change in displacement after 30000 cycles of loading. The torsional stiffness and the maximum torque followed the order SCAP-FN > dynamic hip screw systems (DHS) + derotational screw (DS) > CCS, and the torsional angle corresponding to the maximum torque followed the order SCAP-FN < DHS + DS < CCS. The SCAP-FN construct provides stiffness and stability compared with other standard fixation techniques (3CS and DHS + DS). The fixation strategy of SCAP-FN might be sufficient for clinical use, indicating studies in the human body are warranted.
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Affiliation(s)
- Jia Li
- Department of Orthopedics, Fourth Medical Center, Chinese PLA General Hospital, Beijing, China.,National Clinical Research Center for Orthopaedics, Sports Medicine & Rehabilitation, Beijing, China
| | - Pengbin Yin
- Department of Orthopedics, Fourth Medical Center, Chinese PLA General Hospital, Beijing, China.,National Clinical Research Center for Orthopaedics, Sports Medicine & Rehabilitation, Beijing, China
| | - Jiantao Li
- Department of Orthopedics, Fourth Medical Center, Chinese PLA General Hospital, Beijing, China.,National Clinical Research Center for Orthopaedics, Sports Medicine & Rehabilitation, Beijing, China
| | - Zhe Zhao
- School of Clinical Medicine, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Jingxin Zhao
- Department of Orthopedics, Fourth Medical Center, Chinese PLA General Hospital, Beijing, China.,National Clinical Research Center for Orthopaedics, Sports Medicine & Rehabilitation, Beijing, China
| | - Xiang Cui
- Department of Orthopedics, Fourth Medical Center, Chinese PLA General Hospital, Beijing, China.,National Clinical Research Center for Orthopaedics, Sports Medicine & Rehabilitation, Beijing, China
| | - Houchen Lyu
- Department of Orthopedics, Fourth Medical Center, Chinese PLA General Hospital, Beijing, China.,National Clinical Research Center for Orthopaedics, Sports Medicine & Rehabilitation, Beijing, China
| | - Licheng Zhang
- Department of Orthopedics, Fourth Medical Center, Chinese PLA General Hospital, Beijing, China.,National Clinical Research Center for Orthopaedics, Sports Medicine & Rehabilitation, Beijing, China
| | - Peifu Tang
- Department of Orthopedics, Fourth Medical Center, Chinese PLA General Hospital, Beijing, China.,National Clinical Research Center for Orthopaedics, Sports Medicine & Rehabilitation, Beijing, China
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Adams JDJ, Walker JB, Loeffler M. Avoid the In-Out-In Posterosuperior Femoral Neck Screw: The Use of the Piriformis Fossa Radiographic Landmark. J Orthop Trauma 2022; 36:224-227. [PMID: 34653103 DOI: 10.1097/bot.0000000000002288] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/08/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The most common screw placement across the femoral neck is the inverted triangle. The posterosuperior screw has a high incidence of cortical breach, creating an in-out-in (IOI) screw. This study examined the use of the radiographic landmark of the piriformis fossa (PF) to prevent screws being placed IOI. The hypothesis was that posterior screws placed below the PF inferior margin would prevent femoral neck cortex breach. METHODS Five bilateral cadaveric specimens were used to place 10 screws along the femoral neck posterosuperior cortex. On the AP view, 5 screws were placed in a traditional manner, below the femoral neck superior cortex but above the inferior margin of the PF (APF screws), and 5 were placed below the inferior margin of the PF (BPF). All 10 screws were placed inside the posterior cortex on the lateral view. After screw placement, each hip was dissected, and the femoral necks were evaluated for signs of cortical breach. RESULTS All screws placed below the PF inferior margin were contained within the femoral neck with no incidence of being IOI. All screws placed above the PF inferior margin breached the cortex to a varying degree. All screws were similar in relation to their distance from the posterior cortex on the lateral view, with the APF screws averaging 1.98 mm and the BPF screws averaging 1.82 mm (P value = 0.46). CONCLUSIONS Placing the posterosuperior screw of the inverted triangle caudal to the PF inferior margin on the AP view seems to avoid cortical breach during percutaneous screw fixation of femoral neck fractures.
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Affiliation(s)
- John D Jd Adams
- Department of Orthopedic Surgery, Prisma Health-Upstate, Greenville, SC
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Zelle BA, Salazar LM, Howard SL, Parikh K, Pape HC. Surgical treatment options for femoral neck fractures in the elderly. INTERNATIONAL ORTHOPAEDICS 2022; 46:1111-1122. [DOI: 10.1007/s00264-022-05314-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 01/17/2022] [Indexed: 12/16/2022]
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Fjeld A, Fülling T, Bula P, Bonnaire F. Functional outcomes and perceived quality of life following fixation of femoral neck fractures in adults from 18 to 69 years using dynamic hip screw (DHS) and an additional anti-rotation screw- a retrospective analysis of 53 patients after a mean follow-up time of 4 years. Eur J Trauma Emerg Surg 2022; 48:1893-1903. [PMID: 35039893 DOI: 10.1007/s00068-021-01855-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 12/04/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The purpose of the study was to explore the functional outcome after osteosynthesis with dynamic hip screw (DHS) for adults up to 69 years, and identify potential predictive indicators of either positive impact on quality of life or increase the incidence of complications. MATERIALS AND METHODS Out of 85 patients 53 could be contacted, 36 were followed up clinically and radiologically, 17 patients could be interviewed by phone. All fractures have been treated by osteosynthesis with DHS and one additional anti-rotation screw. Functional outcome and quality of life were measured with use of Harris Hip Score (HHS) and Short Form 12 Health Survey (SF 12). The mean values were compared to two random sample t tests and ANOVA for independent random samples. The connection between an aim variable and selected variables of influence was examined by regression analysis. RESULTS The mean HHS showed good functional results with 88 points (median 95.6). Good or excellent results were achieved in 80.4% of cases. The current investigation also delivers promising results with regard to the complication rate: avascular femoral head necrosis (AVN) in 11.3% of cases (n = 6), 9.4% showed non-union (n = 5) and cut out (n = 3) occurred in 5.7%. A secondary conversion to hip arthroplasty (n = 7) had a strong negative impact on everyday life (HHS = 63.3 points, Physical Health Summary Score SF-12 = 34.9 points). CONCLUSIONS The results of this study are promising showing uncomplicated fracture healing in 84.9% of intracapsular femoral neck fractures and a low incidence of complications after osteosynthesis with DHS in patients aged up to 69 years. The quality of the fracture reduction achieved in the axial view and a small tip apex index after an osteosynthetically treated femoral neck fracture with DHS are significant predictive indicators for complications. Diabetes, age > 65 years, osteoporosis, ASA III may also be significant factors for worse results, but showed no statistical significance in our analysis.
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Affiliation(s)
- Anne Fjeld
- Department of Trauma and Reconstructive Surgery and Hand Surgery, Dresden Municipal Hospital, Friedrichstrasse 41, 01067, Dresden, Germany
| | - Tim Fülling
- Department of Trauma and Reconstructive Surgery and Hand Surgery, Dresden Municipal Hospital, Friedrichstrasse 41, 01067, Dresden, Germany.
| | - Philipp Bula
- Department of Trauma and Reconstructive Surgery and Hand Surgery, Dresden Municipal Hospital, Friedrichstrasse 41, 01067, Dresden, Germany.,Department of Trauma and Reconstructive Surgery, Orthopaedic, Plastic, Aesthetic and Hand Surgery, Guetersloh Municipal Hospital, Guetersloh, Germany
| | - Felix Bonnaire
- Department of Trauma and Reconstructive Surgery and Hand Surgery, Dresden Municipal Hospital, Friedrichstrasse 41, 01067, Dresden, Germany
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Tang Y, Zhang Z, Wang L, Xiong W, Fang Q, Wang G. Femoral neck system versus inverted cannulated cancellous screw for the treatment of femoral neck fractures in adults: a preliminary comparative study. J Orthop Surg Res 2021; 16:504. [PMID: 34399801 PMCID: PMC8365927 DOI: 10.1186/s13018-021-02659-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 08/09/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The femoral neck system (FNS) may be a valid alternative for treating femoral neck fractures, but few studies have compared the outcomes between FNS and cannulated cancellous screws. This study aimed to compare the clinical efficacy and complications of FNS with those of inverted cannulated cancellous screws (ICCS) for the treatment of femoral neck fractures in adults. METHODS This retrospective study evaluated patients with femoral neck fractures who underwent FNS or ICCS internal fixation between June 2019 and January 2020. The operative time, intraoperative blood loss, number of fluoroscopies, length of surgical incision, length of hospital stay, time to fracture healing, and other indicators were compared between the two groups. The incidence of complications such as nonunion, avascular necrosis of the femoral head, loosening of the internal fixation, and shortening of the femoral neck during follow-up was also assessed in both groups. RESULTS Among the 92 patients included, 47 and 45 patients were categorized into the FNS and ICCS groups, respectively. Follow-up ranged from 14 to 24 months. There were no significant between-group differences in sex, age, side of the injured limb, and type of fracture and in operative time, intraoperative blood loss, incision length, and length of hospital stay (all P > 0.05). The incidence of complications such as fracture nonunion, avascular necrosis of the femoral head, and screw loosening was also comparable between the two groups. However, the number of fluoroscopies was significantly lower in the FNS group than in the ICCS group (P < 0.05). The fracture healing time was also significantly lower in the FNS group than in the ICCS group (P < 0.05). Furthermore, the femoral neck shortening and Harris hip score at the last follow-up were significantly better in the FNS group than in the ICCS group (P < 0.05). CONCLUSIONS FNS for femoral neck fractures improves hip functional recovery and reduces the femoral neck shortening rate and fluoroscopy exposure postoperatively. Thus, FNS can be an alternative to ICCS for the treatment of femoral neck fractures.
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Affiliation(s)
- Yunfeng Tang
- Department of Orthopaedics, West China Hospital, West China School of Medicine, Sichuan University, No. 37, Wuhou Guoxue Road, 610041, Chengdu, Sichuan, People's Republic of China
| | - Zhen Zhang
- Department of Orthopaedics, West China Hospital, West China School of Medicine, Sichuan University, No. 37, Wuhou Guoxue Road, 610041, Chengdu, Sichuan, People's Republic of China
| | - Limin Wang
- Department of Orthopaedics, West China Hospital, West China School of Medicine, Sichuan University, No. 37, Wuhou Guoxue Road, 610041, Chengdu, Sichuan, People's Republic of China
| | - Wei Xiong
- Department of Orthopaedics, West China Hospital, West China School of Medicine, Sichuan University, No. 37, Wuhou Guoxue Road, 610041, Chengdu, Sichuan, People's Republic of China
| | - Qian Fang
- Department of Orthopaedics, West China Hospital, West China School of Medicine, Sichuan University, No. 37, Wuhou Guoxue Road, 610041, Chengdu, Sichuan, People's Republic of China
| | - Guanglin Wang
- Department of Orthopaedics, West China Hospital, West China School of Medicine, Sichuan University, No. 37, Wuhou Guoxue Road, 610041, Chengdu, Sichuan, People's Republic of China.
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Lund EA, Samtani R, Winston M, Anderson PA, Whiting PS, O'Toole RV, Hetzel S, Doro CJ. Association of Perioperative Computed Tomography Hounsfield Units and Failure of Femoral Neck Fracture Fixation. J Orthop Trauma 2020; 34:632-638. [PMID: 32433076 DOI: 10.1097/bot.0000000000001843] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/14/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine whether Hounsfield units (HUs) measured on perioperative computed tomographic scans are associated with radiographic outcomes and reoperations after femoral neck fracture fixation. DESIGN Retrospective cohort study. SETTING Level I trauma center. PATIENTS One hundred fourteen patients age ≥18 years, who presented to a Level I trauma center, and who underwent surgical fixation of intracapsular femoral neck fracture and had perioperative computed tomographic scans and adequate follow-up. INTERVENTION None. MAIN OUTCOME MEASUREMENTS Screw penetration, femoral neck shortening >5 mm, and revision surgery. RESULTS A median follow-up was 23 months. An HU measurement of the femoral head was significantly associated with screw penetration and femoral neck shortening but not revision surgery. Patients with middle femoral head HU measurements <146 had 17 times (95% confidence interval: 4.32-78.9, P < 0.001) increased odds of screw penetration. Greater than 5 mm shortening was seen in patients with HUs <212.5 in the low head section by an odds ratio of 7.8 (95% confidence interval: 2.15-33.0, P = 0.014). CONCLUSION Outcome differences regarding screw penetration and femoral neck shortening related to the HU or densities of femoral head and neck at the time of fracture are significant. These findings can help the clinician with developing a treatment plan for either arthroplasty or fixation of a femoral neck fracture based on objective bone quality measurements rather than relying on an arbitrary age recommendation. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Erik A Lund
- Department of Orthopaedics, Allina Health, Minneapolis, MN
| | - Rahul Samtani
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, WI
| | | | - Paul A Anderson
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, WI
| | - Paul S Whiting
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, WI
| | - Robert V O'Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD; and
| | - Scott Hetzel
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, WI
| | - Christopher J Doro
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, WI
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Lag screw with DHS (LSD) for vertical angle femoral neck fractures in young adults. Injury 2020; 51:2628-2633. [PMID: 32739149 DOI: 10.1016/j.injury.2020.07.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/21/2020] [Accepted: 07/24/2020] [Indexed: 02/02/2023]
Abstract
Vertical Pauwels Type III fractures of the neck of femur in young patients are difficult fractures to treat. These are usually as a result of high energy trauma which are associated with a significant degree of fracture comminution in the neck of femur. This makes the fracture reduction and fixation difficult. Many fixation methods and implants have been described for use in these fractures but are not without reported complications such as non-union and varus collapse. In this article, we highlight the incidence of fracture comminution in both the anterior and posterior cortices of the femoral neck, better visualised with axial computed tomography scanning and describe a simple technique utilizing lag screws and a DHS implant to adequately address these fractures.
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Campenfeldt P, Ekström W, Al-Ani AN, Weibust E, Greve K, Hedström M. Health related quality of life and mortality 10 years after a femoral neck fracture in patients younger than 70 years. Injury 2020; 51:2283-2288. [PMID: 32620326 DOI: 10.1016/j.injury.2020.06.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 05/26/2020] [Accepted: 06/15/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND PURPOSE A femoral neck fracture (FNF) may have long term effects on the patient's health related quality of life (HRQoL) and mortality, especially in patients younger than 70 years. These long-term effects are unknown since most studies have a short follow-up. The aim of this study was to investigate self-assessed hip function, HRQoL and factors associated with 10-years mortality after a FNF. PATIENTS AND METHODS A prospective multicenter study with a 10-year follow-up of patients aged 20-69 years with a displaced and non-displaced FNF treated with closed reduction and internal fixation. The self-administered questionnaires EuroQol 5 Dimension (EQ-5D) and Hip Disability Outcome Score (HOOS) were used. Results of EQ-5D and HOOS was compared to sex and age matched general population data of Sweden. All patients that were deceased had their death date recorded. Factors associated with mortality were assessed by regression analysis of the baseline data including age, gender, harmful alcohol consumption according to AUDIT, co-morbidity measured by ASA-grade, body mass index, osteoporosis measured by dual energy x-ray absorptiometry (DXA) and smoking. Prevalence of co-morbidities and smoking was compared to general population data. RESULTS From initial 182 included patients, 55 were deceased at 10-year follow-up, 4 were deregistered from public record and 35 declined participations. A total of 88 patients participated through self-administrated questionnaires. There were no significant differences in HOOS between gender and fracture type and the results were equivalent to general population data. The EQ-5D continued to improve compared to a 24-month follow-up (p = 0.006) but did not recover to pre-fracture level (p<0.001) though it was equivalent to general population data. Higher age, co-morbidity, osteoporosis and smoking were associated with increased mortality within 10 years after the fracture and the prevalence of co-morbidity and smoking was higher than the general population. INTERPRETATION Those patients who had survived 10 years after a FNF treated with CRIF had a HRQoL and hip function equivalent to age and sex matched general population of Sweden. However, a third of these relatively young patients had deceased 10 years after the hip fracture and they were more compromised than the general population.
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Affiliation(s)
- Pierre Campenfeldt
- Karolinska Institutet, Department of Clinical Science Intervention and Technology, Sweden; Swedish Armed Forces, Defence Inspector for Medicine and Environmental Health, Tegeluddsvägen 100 SE-107 85, Stockholm, Sweden.
| | - Wilhelmina Ekström
- Karolinska Institutet, Department of Molecular Medicine and Surgery, Section of rthopaedics and Sports Medicine, Department of Orthopaedics Karolinska University Hospital Solna, Stockholm, Sweden
| | - Amer N Al-Ani
- Karolinska Institutet, Department of Clinical Science Intervention and Technology, Sweden; Orthopaedic Clinic, Vällingby-Läkarhuset, Praktikertjänst AB, Sweden
| | | | - Katarina Greve
- Karolinska Institutet, Department of Clinical Science Intervention and Technology, Sweden; Perioperative Medicine and Intensive Care, Karolinska University Hospital Huddinge, Sweden
| | - Margareta Hedström
- Karolinska Institutet, Department of Clinical Science Intervention and Technology, Sweden; Department of Orthopaedics, Karolinska University Hospital, Huddinge, Sweden
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Luo J, Ajami S, Yu H, Ma S, Chen S, Zhou F, Wang P, Yao X, Liu C. Fretting corrosion of screws contribute to the fixation failure of the femoral neck: a case report. BIOSURFACE AND BIOTRIBOLOGY 2019. [DOI: 10.1049/bsbt.2019.0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Jiajun Luo
- Division of Surgery & Interventional ScienceInstitute of Orthopaedic & Musculoskeletal ScienceUniversity College LondonRoyal National Orthopaedic HospitalStanmoreHA7 4LPUK
| | - Sara Ajami
- Division of Surgery & Interventional ScienceInstitute of Orthopaedic & Musculoskeletal ScienceUniversity College LondonRoyal National Orthopaedic HospitalStanmoreHA7 4LPUK
| | - Hai‐Ming Yu
- Department of OrthopaedicsSecond Affiliated Hospital of Fujian Medical UniversityQuanzhou362000People's Republic of China
| | - Shuanhong Ma
- State Key Laboratory of Solid LubricationLanzhou Institute of Chemical PhysicsChinese Academy of SciencesLanzhou730000People's Republic of China
| | - Shen‐Mao Chen
- Division of Surgery & Interventional ScienceInstitute of Orthopaedic & Musculoskeletal ScienceUniversity College LondonRoyal National Orthopaedic HospitalStanmoreHA7 4LPUK
| | - Feng Zhou
- State Key Laboratory of Solid LubricationLanzhou Institute of Chemical PhysicsChinese Academy of SciencesLanzhou730000People's Republic of China
| | - Pei‐Wen Wang
- Department of OrthopaedicsSecond Affiliated Hospital of Fujian Medical UniversityQuanzhou362000People's Republic of China
| | - Xue‐Dong Yao
- Department of OrthopaedicsSecond Affiliated Hospital of Fujian Medical UniversityQuanzhou362000People's Republic of China
| | - Chaozong Liu
- Division of Surgery & Interventional ScienceInstitute of Orthopaedic & Musculoskeletal ScienceUniversity College LondonRoyal National Orthopaedic HospitalStanmoreHA7 4LPUK
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Kuan FC, Hsu KL, Lin CL, Hong CK, Yeh ML, Su WR. Biomechanical properties of off-axis screw in Pauwels III femoral neck fracture fixation: Bicortical screw construct is superior to unicortical screw construct. Injury 2019; 50:1889-1894. [PMID: 31431332 DOI: 10.1016/j.injury.2019.07.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 07/11/2019] [Accepted: 07/19/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The purpose of this study is to determine the biomechanical properties of the bicortical off-axis screw fixation for stabilizing of Pauwels III femoral neck fractures compared with other fixation methods. METHODS Eighteen synthetic femurs (Sawbones Pacific Research Laboratories, Vashon, WA) were divided into three groups. The osteotomy was made vertically to mimic the Pauwels type III femoral neck fracture. Group A (n = 6) was fixed with traditional inverted triangle cannulated screws. Group B (n = 6) was fixed with a unicortical off-axis screw and two parallel cannulated screws. Group C (n = 6) was fixed with a bicortical off-axis screw and two parallel cannulated screws. Each group was tested with a nondestructive axial compression test at a 7° of valgus followed with 1000 cycles of cyclic loading test from 100 N to 1000 N. Finally, a destructive axial compression test was applied until catastrophic failure. RESULTS The average axial stiffness from group A to group C was 856.5, 934, and 1340 N/mm, respectively. The average ultimate failure load from group A to group C was 2612.7, 2508.8, and 3706 N, respectively. Group C exhibited significantly greater axial stiffness and a higher ultimate failure load than the other two groups (P < 0.05). Regarding the interfragmental displacement, the values from group A to group C were 0.41, 0.83, 0.36, respectively, and group B exhibited significantly larger fracture gap formation after the cyclic loading test. CONCLUSIONS The results of this biomechanical study show statistically significant increases in axial stiffness and ultimate failure load for the off-axis screw placed in bicortical fashion. Once the off-axis screw was positioned unicortically, the largest fracture diastasis was observed as compared to the other two methods.
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Affiliation(s)
- Fa-Chuan Kuan
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan; Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Kai-Lan Hsu
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan; Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Cheng-Li Lin
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan; Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Kai Hong
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ming-Long Yeh
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Ren Su
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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Stockton DJ, Dua K, O'Brien PJ, Pollak AN, Hoshino CM, Slobogean GP. Failure Patterns of Femoral Neck Fracture Fixation in Young Patients. Orthopedics 2019; 42:e376-e380. [PMID: 30913299 DOI: 10.3928/01477447-20190321-03] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 10/03/2018] [Indexed: 02/03/2023]
Abstract
The primary purpose of this study was to describe the failure patterns of femoral neck fracture fixation in young patients. The secondary purpose was to determine if pattern of failure varies by type of implant. Adult patients (age range, 18-55 years) who experienced a "fixation failure" following internal fixation of a femoral neck fracture were identified from 5 level 1 trauma centers. Failure was defined by screw cutout, implant breakage, varus collapse (<120° neck-shaft angle), or severe fracture shortening (≥1 cm). When multiple complications were identified, mechanical failures were preferentially noted for the analysis. Failure patterns were compared between patients who received multiple cancellous screws and patients who received a sliding hip screw plus a derotation screw. Severe fracture shortening was the most common complication identified (61%). No differences in the incidence of severe shortening (P=.750) or implant breakage (P=1.000) were detected between the fixation groups. However, among the failures with a sliding hip screw plus a derotation screw construct, a greater portion were related to screw cutout (38% for a sliding hip screw plus a derotation screw vs 7% for screws, P=.019). Failures with multiple screws were associated with varus collapse (25% for screws vs 0% for a sliding hip screw plus a derotation screw, P=.037). Severe shortening was the most common fixation failure. Sliding hip screw plus derotation screw implants were associated with screw cutout. Multiple cancellous screw implants failed by varus collapse. Selecting a surgical implant based on its likely failure pattern may allow surgeons to minimize the severity of failure or the need for secondary conversion to hip arthroplasty. [Orthopedics. 2019; 42(4):e376-e380.].
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Biplane Double-supported Screw Fixation of Femoral Neck Fractures: Surgical Technique and Surgical Notes. J Am Acad Orthop Surg 2019; 27:e507-e515. [PMID: 30399029 PMCID: PMC6530978 DOI: 10.5435/jaaos-d-17-00117] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Osteosynthesis of femoral neck fractures is still associated with high complication rates. The novel method of biplane double-supported screw fixation offers better osteosynthesis stability by buttressing two of three medially diverging cannulated screws on the inferior neck cortex. Biomechanically, the most effective component of this fixation is the third, inferior obtuse screw, supported along considerable distance on both the inferior and posterior cortices of the femoral neck following its spiral anterior curve. Thus, biplane double-supported screw fixation achieves greater inferoposterior cortical support of the implants, allowing immediate full weight bearing for patients older than 55 years. Although the method has been recently communicated, some important surgical aspects still remain to be discussed. This report aims at describing a detailed and modified surgical technique and providing criteria and recommendations for its successful application according to the clinical experience over more than 9 years. LEVEL OF EVIDENCE:: Level V, expert evidence.
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15
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Boughton OR, Ma S, Cai X, Yan L, Peralta L, Laugier P, Marrow J, Giuliani F, Hansen U, Abel RL, Grimal Q, Cobb JP. Computed tomography porosity and spherical indentation for determining cortical bone millimetre-scale mechanical properties. Sci Rep 2019; 9:7416. [PMID: 31092837 PMCID: PMC6520408 DOI: 10.1038/s41598-019-43686-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 04/23/2019] [Indexed: 12/11/2022] Open
Abstract
The cortex of the femoral neck is a key structural element of the human body, yet there is not a reliable metric for predicting the mechanical properties of the bone in this critical region. This study explored the use of a range of non-destructive metrics to measure femoral neck cortical bone stiffness at the millimetre length scale. A range of testing methods and imaging techniques were assessed for their ability to measure or predict the mechanical properties of cortical bone samples obtained from the femoral neck of hip replacement patients. Techniques that can potentially be applied in vivo to measure bone stiffness, including computed tomography (CT), bulk wave ultrasound (BWUS) and indentation, were compared against in vitro techniques, including compression testing, density measurements and resonant ultrasound spectroscopy. Porosity, as measured by micro-CT, correlated with femoral neck cortical bone's elastic modulus and ultimate compressive strength at the millimetre length scale. Large-tip spherical indentation also correlated with bone mechanical properties at this length scale but to a lesser extent. As the elastic mechanical properties of cortical bone correlated with porosity, we would recommend further development of technologies that can safely measure cortical porosity in vivo.
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Affiliation(s)
- Oliver R Boughton
- The MSk Lab, Department of Surgery and Cancer, Imperial College London, London, United Kingdom.
- The Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, United Kingdom.
| | - Shaocheng Ma
- The MSk Lab, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- The Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, United Kingdom
| | - Xiran Cai
- Sorbonne Université, INSERM, CNRS, Laboratoire d'Imagerie Biomédicale, F-75006, Paris, France
| | - Liye Yan
- Department of Materials, University of Oxford, Oxford, United Kingdom
| | - Laura Peralta
- Sorbonne Université, INSERM, CNRS, Laboratoire d'Imagerie Biomédicale, F-75006, Paris, France
| | - Pascal Laugier
- Sorbonne Université, INSERM, CNRS, Laboratoire d'Imagerie Biomédicale, F-75006, Paris, France
| | - James Marrow
- Department of Materials, University of Oxford, Oxford, United Kingdom
| | - Finn Giuliani
- Centre for Advanced Structural Ceramics, Department of Materials, Imperial College London, London, United Kingdom
| | - Ulrich Hansen
- The Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, United Kingdom
| | - Richard L Abel
- The MSk Lab, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Quentin Grimal
- Sorbonne Université, INSERM, CNRS, Laboratoire d'Imagerie Biomédicale, F-75006, Paris, France
| | - Justin P Cobb
- The MSk Lab, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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Liu C, Von Keudell A, McTague M, Rodriguez EK, Weaver MJ. Ideal length of thread forms for screws used in screw fixation of nondisplaced femoral neck fractures. Injury 2019; 50:727-732. [PMID: 30772052 DOI: 10.1016/j.injury.2019.01.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 12/29/2018] [Accepted: 01/30/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND It is common practice when placing cannulated screws within the femoral head when treating femoral neck fractures to avoid the thread-forms from crossing the fracture line. Despite the widespread use of cannulated screws in internal fixation of femoral neck fractures, there is no study to our knowledge that describes the ideal length of thread-forms. PURPOSE The purpose of this study is to determine the thread length that will maximize purchase within the femoral head while minimizing risk of crossing the fracture line. Additional analysis was conducted to identify factors associated with the maximal possible length of treads in minimally and non-displaced femoral neck fractures. METHODS We performed a retrospective study of all patients treated for a minimally or non-displaced femoral neck fracture from April 1, 2004 through December 31, 2017. Only patients who had received a pre-operative CT or MRI scan were included. Fixation was then templated using radiographs and the distance from the subchondral bone to the fracture line was then measured. RESULTS The study included 127 patients. The average estimated length of lag screw threads was 33.2 ± 6.67 mm, with lower quartile of 29.1 mm and higher quartile of 37.2 mm. The median was 32.0 mm and most frequently encountered estimate was 29 mm. Estimated lag screw size did not differ significantly based on age or BMI, but both height (p < 0.001) and race (0.04) were positively correlated with estimated lag screw size and males had longer measurements compared to females, 37.2 ± 7.0 mm vs 31.4 ± 5.7 mm (p < 0.001), respectively. CONCLUSION In conclusion, we propose an additional lag screw thread form with length 26.0 mm to capture 90% of femoral neck fractures.
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Affiliation(s)
- Christina Liu
- Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.
| | - Arvind Von Keudell
- Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, MA, USA; Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.
| | - Michael McTague
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.
| | - Edward K Rodriguez
- Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Michael J Weaver
- Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.
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17
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Guo J, Dong W, Yin B, Jin L, Lin Z, Hou Z, Zhang Y. Intramedullary nails with cannulated screw fixation for the treatment of unstable femoral neck fractures. J Int Med Res 2019; 47:557-568. [PMID: 30526163 PMCID: PMC6381514 DOI: 10.1177/0300060518816185] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 11/05/2018] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE Unstable femoral neck fractures are typically high-angled shear fractures caused by high-energy trauma. Internal fixation of femoral neck fractures with placement of parallel cannulated screws in an inverted triangle configuration is commonly performed in the clinical setting. This study was performed to investigate the primary results of intramedullary nailing with cannulated screws for the treatment of unstable femoral neck fractures in young and middle-aged patients. METHODS In total, 96 consecutive patients with no history of hip surgery using inverted triangular cannulated compression screws or construction nails with cannulated screws were reviewed. Their demographic and radiological data were retrospectively collected from our institutional database. RESULTS Inverted cannulated screws had an excellent effect on decreasing the blood loss volume and incision size, but intramedullary nails exhibited superior advantages in decreasing screw exit and shortening the hospital stays. The Harris hip scores were comparable between the two groups. CONCLUSIONS Intramedullary fixation with cannulated screws has advantages in treating complicated femoral neck fractures. Besides cannulated screws, intramedullary fixation with cannulated screws might be another method to treat unstable femoral neck fractures in young and middle-aged patients. The study was registered in ClinicalTrials.gov. Unique Protocol ID: 11156458. The ClinicalTrial number is NCT03550079.
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Affiliation(s)
- Jialiang Guo
- Department of Orthopaedic Surgery, the Third Hospital of Hebei
Medical University, Shijiazhuang, PR China
- Key Laboratory of Orthopaedic Biomechanics of Hebei Province,
Shijiazhuang, PR China
- Orthopaedic Research Institution of Hebei Province, Hebei, PR
China
| | - Weichong Dong
- Department of Pharmacy, the Second Hospital of Hebei Medical
University, Shijiazhuang, PR China
| | - Bing Yin
- Department of Orthopaedic Surgery, the Third Hospital of Hebei
Medical University, Shijiazhuang, PR China
- Key Laboratory of Orthopaedic Biomechanics of Hebei Province,
Shijiazhuang, PR China
- Orthopaedic Research Institution of Hebei Province, Hebei, PR
China
| | - Lin Jin
- Department of Orthopaedic Surgery, the Third Hospital of Hebei
Medical University, Shijiazhuang, PR China
- Key Laboratory of Orthopaedic Biomechanics of Hebei Province,
Shijiazhuang, PR China
- Orthopaedic Research Institution of Hebei Province, Hebei, PR
China
| | - Zhe Lin
- Department of Orthopaedic Surgery, the Third Hospital of Hebei
Medical University, Shijiazhuang, PR China
- Key Laboratory of Orthopaedic Biomechanics of Hebei Province,
Shijiazhuang, PR China
- Orthopaedic Research Institution of Hebei Province, Hebei, PR
China
| | - Zhiyong Hou
- Department of Orthopaedic Surgery, the Third Hospital of Hebei
Medical University, Shijiazhuang, PR China
- Key Laboratory of Orthopaedic Biomechanics of Hebei Province,
Shijiazhuang, PR China
| | - Yingze Zhang
- Department of Orthopaedic Surgery, the Third Hospital of Hebei
Medical University, Shijiazhuang, PR China
- Key Laboratory of Orthopaedic Biomechanics of Hebei Province,
Shijiazhuang, PR China
- Orthopaedic Research Institution of Hebei Province, Hebei, PR
China
- Chinese Academy of Engineering, Beijing, PR China
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18
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Abstract
Young femoral neck fractures remain challenging fractures to treat. Reduction has repeatedly been shown to be the single most important determinant of patient outcome, and treating surgeons should do all they can to achieve anatomic reduction because this is an outcome variable within the surgeon's control. Whether an open or closed reduction is performed, we hope to provide the reader with reduction strategies when faced with this difficult fracture pattern. In addition, we hope to review indications and techniques for using the various treatment implants/modalities that are currently available as they pertain to reduction and fixation.
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Campenfeldt P, Al-Ani A, Hedström M, Ekström W. Low BMD and high alcohol consumption predict a major re-operation in patients younger than 70 years of age with a displaced femoral neck fracture-A two -year follow up study in 120 patients. Injury 2018; 49:2042-2046. [PMID: 30243652 DOI: 10.1016/j.injury.2018.09.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Revised: 09/07/2018] [Accepted: 09/09/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND PURPOSE The recommended treatment of displaced femoral neck fractures (FNF) in patients younger than 70 years of age is fracture reduction and internal fixation (IF). The incidence of re-operation due to nonunion (NU) or avascular necrosis (AVN) has been reported to be between 20-30%. Knowledge of possible predisposing factors needs to be elucidated. The primary aim of this study was to identify factors associated with a major re-operation due to NU or AVN in patients <70 years with a displaced FNF treated with IF. PATIENTS AND METHODS 128 patients, 20-69 years with a FNF treated with IF. Follow up included radiographic and clinical examination at 4, 12 and 24 months. Logistic regression analysis was used to identify factors associated with re-operation due to NU or AVN. RESULTS The re-operation rate due to NU or AVN was 6%, 16% and 28% at 4, 12 and 24 months respectively. Patients with low BMD was more likely to be re-operated than those with normal BMD, OR 5.5, CI (95%) 1.15-26.8, and those with a high alcohol consumption had 3.2 times higher odds to be re-operated due to NU or AVN, CI (95%) 1.16-8.76. INTERPRETATION In more than two thirds (83/120) of the patients the fracture healed after one operation. Moreover, a low BMD and high alcohol consumption were related to a major re-operation. These results suggest that only age as a sole variable for choosing the type of surgical treatment may not be rational.
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Affiliation(s)
- Pierre Campenfeldt
- Karolinska Institutet, Department of Clinical Science Intervention and Technology, Sweden; Swedish Armed Forces, Defence Inspector for Medicine and Environmental Health, Tegeluddsvägen 100 SE-107 85, Stockholm, Sweden.
| | - Amer Al-Ani
- Karolinska Institutet, Department of Clinical Science Intervention and Technology, Sweden; Orthopedic Clinic, Vällingby-Läkarhuset, Praktikertjänst AB, Sweden
| | - Margareta Hedström
- Karolinska Institutet, Department of Clinical Science Intervention and Technology, Sweden; Department of Orthopaedics, Karolinska University Hospital, Sweden
| | - Wilhelmina Ekström
- Department of Orthopaedics, Karolinska University Hospital, Sweden; Karolinska Institutet, Department of Molecular Medicine and Surgery, Section of Orthopaedics and Sport Medicine, Sweden
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Increased torsional stability by a novel femoral neck locking plate. The role of plate design and pin configuration in a synthetic bone block model. Clin Biomech (Bristol, Avon) 2018; 55:28-35. [PMID: 29653317 DOI: 10.1016/j.clinbiomech.2018.03.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 03/23/2018] [Accepted: 03/26/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND In undisplaced femoral neck fractures, internal fixation remains the main treatment, with mechanical failure as a frequent complication. As torsional stable fixation promotes femoral neck fracture healing, the Hansson Pinloc® System with a plate interlocking pins, was developed from the original hook pins. Since its effect on torsional stability is undocumented, the novel implant was compared with the original configurations. METHODS Forty-two proximal femur models custom made of two blocks of polyurethane foam were tested. The medial block simulated the cancellous head, while the lateral was laminated with a glass fiber filled epoxy sheet simulating trochanteric cortical bone. Two hollow metal cylinders with a circumferential ball bearing in between mimicked the neck, with a perpendicular fracture in the middle. Fractures were fixated by two or three independent pins or by five configurations involving the interlocking plate (two pins with an optional peg in a small plate, or three pins in a small, medium or large plate). Six torsional tests were performed on each configuration to calculate torsional stiffness, torque at failure and failure energy. FINDINGS The novel configurations improved parameters up to an average of 12.0 (stiffness), 19.3 (torque) and 19.9 (energy) times higher than the original two pins (P < 0.001). The plate, its size and its triangular configuration improved all parameters (P = 0.03), the plate being most effective, also preventing permanent failure (P < 0.001). INTERPRETATION The novel plate design with its pin configuration enhanced torsional stability. To reveal clinical relevance a clinical study is planned.
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21
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Schwartsmann CR, Lammerhirt HM, Spinelli LDF, Ungaretti Neto ADS. Treatment of displaced femoral neck fractures in young patients with DHS and its association to osteonecrosis. Rev Bras Ortop 2018; 53:82-87. [PMID: 29367911 PMCID: PMC5771783 DOI: 10.1016/j.rboe.2017.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 01/17/2017] [Indexed: 02/07/2023] Open
Abstract
Objective The purpose of this study is to evaluate the performance of dynamic hip screw for the treatment of dislocated femoral neck fractures in young patients, focusing on osteonecrosis. Methods A series of 53 patients with less than 55 years of age were retrospectively evaluated. All patients had dislocated femoral neck fractures (Garden III or IV) and were treated with DHS. Ficat's staging system was used to evaluate avascular necrosis. Results There were 38 (71.7%) males and 15 (28.3%) females, with an overall mean age at the onset of fracture of 41.9 years (±12.8). According to Garden's classification, 21 (39.6%) fractures were classified as type III and 32 (60.4%) were considered totally dislocated, Garden IV. Fracture healing was achieved in 39 patients (73.6%). Thirteen cases of avascular necrosis were observed (24.6%). Conclusions The incidence of avascular necrosis in young patients with a displaced femoral neck fractures treated with DHS was 24.6%. No statistically significant association was found between times elapsed to surgery, fracture displacement, and presence of derotation screw with osteonecrosis. Level of evidence IV.
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Affiliation(s)
- Carlos Roberto Schwartsmann
- Departamento de Ortopedia e Traumatologia, Universidade Federal de Ciências da Saúde, Porto Alegre, RS, Brazil.,Departamento de Ortopedia e Traumatologia, Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil
| | - Henrique Marquardt Lammerhirt
- Departamento de Ortopedia e Traumatologia, Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil
| | - Leandro de Freitas Spinelli
- Departamento de Ortopedia e Traumatologia, Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil
| | - Ary da Silva Ungaretti Neto
- Departamento de Ortopedia e Traumatologia, Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil
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22
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Tratamento de fraturas deslocadas do colo femoral em pacientes jovens com DHS e associação com a osteonecrose. Rev Bras Ortop 2018. [DOI: 10.1016/j.rbo.2017.01.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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Harris E, Moroney P, Tourné Y. Arthrodesis of the first metatarsophalangeal joint-A biomechanical comparison of four fixation techniques. Foot Ankle Surg 2017; 23:268-274. [PMID: 29202986 DOI: 10.1016/j.fas.2016.07.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 06/17/2016] [Accepted: 07/11/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Arthrodesis of the first metatarsophalangeal joint is a commonly performed orthopaedic procedure. The optimum method of fixation and joint surface preparation has yet to be determined. METHODS This study compared four fixation techniques: Biomechanical grade sawbones were used. The dorsal plate used was a titanium, anatomically contoured locked plate. Testing was performed using an Instron machine applying force from the plantar aspect of the fused joint. Each fused sample was tested to failure. Stiffness, as calculated from the force-displacement curve, and ultimate load tolerated were recorded for each sample. The method of failure of each sample was also documented. RESULTS Constructs arthrodesed using dorsal plate with separate screw groups, regardless of method of joint preparation, were the stiffest (p<0.001). The weakest construct was dorsal plate alone without interfragmenary screw. There was no difference in stiffness between planar and cup-cone joint preparation (p=0.99). Maximum load tolerated was similar when comparing Crossed Screws with dorsal plate with screw with either cup-cone or planar reaming (p=0.93, p=0.89 respectively). Dorsal plating alone tolerated a significantly lower maximum load than Plate with Screw Groups or Crossed Screws (p<0.001). CONCLUSION This study confirms that an IFS combined with a dorsally positioned locked-plate is the ideal construct, with the joint preparation technique of little consequence.
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Affiliation(s)
- Ella Harris
- Biomedical Sciences Institute, Trinity College Dublin, 152-160 Pearse Street, Dublin 2, Ireland.
| | - Paul Moroney
- Department of Orthopaedic Surgery, Mater Misericordiae Hospital, Eccles Street, Dublin 7, Ireland.
| | - Yves Tourné
- Clinique des Cedres, 38130 Echirolles, France.
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24
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Abstract
BACKGROUND During osteosynthesis standard nonlocking cortical screws often require reinsertion, raising concern over possible decrease in their effectiveness. This study aims to quantify that potential loss of fixation with reinsertions as well as examine the ability of a cancellous "bailout screw" to regain insertion torque in a previously stripped screw hole. METHODS Four different types of bone surrogates were chosen to represent normal cortical bone, osteoporotic cortical bone, high-density (normal) cancellous bone, and low-density (osteoporotic) cancellous bone; nonlocked 3.5-mm cortical screws were inserted into the predrilled holes 1, 2, 3, 4, or 5 times before being torqued maximally to the point of stripping. A 4.0-mm cancellous "bailout" screw was then placed into the same hole and torqued until stripping. Torque was measured continuously using a torque-measuring screwdriver and maximal insertion torque (MIT) of 3.5 and 4.0 screws before stripping was recorded. RESULTS MIT decreased with reinsertion of nonlocked cortical screws. By the third reinsertion in all but the normal bone surrogates, the screws lost approximately one third to one half of their original MIT (50%-71% of original torque). The bailout screw succeeded in restoring the original MIT in the osteoporotic cancellous bone surrogate and the normal cortical bone surrogate. In the normal cancellous and osteoporotic cortical bone surrogates, the bailout screw was only able to restore an average of 50% (range 31%-63%) of the original MIT. CONCLUSIONS Screw reinsertion may significantly reduce the MIT of 3.5-mm nonlocked cortical screws. Use of the bailout cancellous screw for a stripped cortical screw should be expected to restore MIT only in normal cortical bone and osteoporotic cancellous bone. In other scenarios, the bailout screw should not be expected to uniformly restore full insertion torque.
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Fixation of displaced femoral neck fractures in young adults: Fixed-angle devices or Pauwel screws? Injury 2016; 47:1676-84. [PMID: 27269418 DOI: 10.1016/j.injury.2016.03.014] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 03/03/2016] [Accepted: 03/09/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND We sought to compare the incidence of complications after fixation of displaced femoral neck fractures in young adults treated with fixed-angle devices versus multiple cancellous screws and a trochanteric lag screw (Pauwel screw). METHODS We conducted a retrospective cohort study at a level I trauma centre. Sixty-two skeletally mature patients (age range, 16-60 years) with displaced femoral neck fractures were included in the study. Forty-seven were treated with a fixed-angle device (sliding hip plate with screw or helical blade) and 15 with multiple cancellous screws placed in a Pauwel configuration. The main outcome measure was postoperative complication of osteonecrosis or nonunion treated with a surgical procedure. RESULTS Significantly fewer failures occurred in the fixed-angle group (21%) than in the screws group (60%) (p=0.008). Osteonecrosis was rare in the fixed-angle group, occurring in 2% of cases versus 33% of cases in the screws group (p=0.002). Consistent with previous studies, good to excellent reductions were associated with a failure rate of 25% and fair to poor reductions were associated with a failure rate of 55% (p=0.07). The best-case scenario of a good to excellent reduction stabilised with a fixed-angle device yielded a success rate of 85%. CONCLUSION In young patients with displaced high-energy femoral neck fractures, fixed-angle devices resulted in fewer treatment failures than did Pauwel screws.
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The effect of local bone density on mechanical failure after internal fixation of pertrochanteric fractures. Arch Orthop Trauma Surg 2016; 136:223-32. [PMID: 26626056 DOI: 10.1007/s00402-015-2369-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Indexed: 02/09/2023]
Abstract
INTRODUCTION The aim of this prospective study was to investigate the effect of local hip bone density on mechanical failure after fixation of pertrochanteric fractures and to establish possible risk factors for the failures. MATERIALS AND METHODS A total of 136 consecutive patients presenting a closed unilateral pertrochanteric fracture were enrolled. The patients were treated with a sliding hip screw or an intramedullary nail. Dual energy X-ray absorptiometry measurements for bone density of the contralateral hip were made within 4 weeks postoperatively. Follow-up evaluations on the standard radiographs were documented for any mechanical failure including loss of reduction, screw or blade cut-out, lateral migration of the screw or blade, and implant breakage. Secondary outcomes were also recorded including patient characteristics and fixation construct variables as possible predictors for mechanical failure. RESULTS At a minimum of 2 years of follow-up, 38 patients were reported with mechanical failure at an estimated risk of 27.9 %. The local bone density measurements for the study population showed no difference between patients with (0.710 g/cm(2)) and without (0.726 g/cm(2)) mechanical failure (P = 0.180). We also observed no significant correlation between local bone density and failure in patients with good fracture reduction (P = 0.862). The multivariate regression analysis identified fracture type (P < 0.001) and quality of fracture reduction (P < 0.001) as being independent predictors for mechanical failure, whereas local bone density was not (P = 0.658). CONCLUSIONS Local hip bone density does not appear to have a significant influence on mechanical failure after internal fixation of pertrochanteric fractures. Stable fractures and fractures with good reduction are expected to obtain satisfactory outcomes.
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Park BJ, Cho HM, Min WB. Surgical Treatment of Undisplaced Femur Neck Fractures in Dementia Patients Using Proximal Femoral Nail Antirotation. Hip Pelvis 2015; 27:164-72. [PMID: 27536620 PMCID: PMC4972721 DOI: 10.5371/hp.2015.27.3.164] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 08/02/2015] [Accepted: 08/26/2015] [Indexed: 12/22/2022] Open
Abstract
Purpose People with dementia have poor mobility and discharge outcomes following hip fractures. The purpose of this study was to evaluate the clinical and radiological results of internal fixation of undisplaced femur neck fractures (Garden types 1 and 2) by proximal femoral nail antirotation (PFNA) in dementia patients. Materials and Methods We studied retrospectively 19 patients with undisplaced femur neck fracture. All patients were over 70 years of age, walked independently with a cane or crutches and suffered moderate-to-severe dementia. Patients were treated with PFNA and followed-up for more than 2 years. Revision, loss of fixation, complications, and walking ability outcomes were measured. Results In walking-ability evaluation, patients showed an average decrease of just 0.2 points at the final follow-up. Walking ability was evaluated from before injury to 4 weeks after surgery and decreased by less than 0.5 points. Radiological bone union was achieved in 17 cases; the average time to bone union was 4.14 months (range, 2.5-7 months). Complications included non-union in two cases and femoral head avascular necrosis in one case of non-union. Conclusion We found that for patients with osteoporotic bone tissues in their femoral heads or patients (e.g., those suffering dementia) for whom cooperating with medical workers for postoperative walking control or rehabilitation exercises is difficult, implanting a mechanically stable spiral blade for fixation of femoral neck fractures could facilitate walking after surgery.
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Affiliation(s)
- Bong-Ju Park
- Department of Orthopedic Surgery, Gwangju Veterans Hospital, Gwangju, Korea
| | - Hong-Man Cho
- Department of Orthopedic Surgery, Gwangju Veterans Hospital, Gwangju, Korea
| | - Woong-Bae Min
- Department of Orthopedic Surgery, Gwangju Veterans Hospital, Gwangju, Korea
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Stockton DJ, Lefaivre KA, Deakin DE, Osterhoff G, Yamada A, Broekhuyse HM, OʼBrien PJ, Slobogean GP. Incidence, Magnitude, and Predictors of Shortening in Young Femoral Neck Fractures. J Orthop Trauma 2015; 29:e293-8. [PMID: 26226462 DOI: 10.1097/bot.0000000000000351] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To describe the incidence and magnitude of femoral neck fracture shortening in patients age younger than 60 years. Secondarily, to examine predictors of fracture shortening. DESIGN Retrospective chart review. SETTING Level I trauma centre. PATIENTS/PARTICIPANTS Sixty-five patients with a median age of 51 years (interquartile range: 42-56 years) were included. Seventy-one percent were male, 75% were displaced fractures, and 78% were treated with cancellous screws. INTERVENTION Internal fixation with multiple cancellous screws or sliding hip screw (SHS) + derotation screw. MAIN OUTCOME MEASUREMENTS Radiographic femoral neck shortening at a minimum of 6 weeks after fixation. RESULTS Fifty-four percent of patients had ≥5 mm of femoral neck shortening (22% had between ≥5 and <10 mm and 32% ≥10 mm). Initially, displaced fractures shortened more than undisplaced fractures (mean: 8.1 vs. 2.2 mm, P < 0.001), and fractures treated with SHS + derotation screw shortened more than fractures with cancellous screws alone (10.7 vs. 5.5 mm, P = 0.03). Even when adjusting for initial fracture displacement, fractures treated with SHS + derotation screw shortened an average of 2.2 mm more than fractures treated with screws alone (P = 0.03). CONCLUSIONS The incidence of clinically significant shortening in our young femoral neck fracture population was higher than anticipated, and 32% of patients experienced severe shortening of >1 cm. Our findings highlight the need for further research to determine the impact of severe shortening on functional outcome and to determine if implant selection affects fracture shortening. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- David J Stockton
- *Division of Orthopaedic Trauma, Department of Orthopaedics, Centre for Hip Health and Mobility, University of British Columbia, Vancouver, British Columbia, Canada; †Consultant Orthopaedic Trauma Surgeon, Nottingham University Hospital, Nottingham, United Kingdom; and ‡Vancouver-Fraser Medical Program, Faculty of Medicine, University of British Columbia, Vancouver British Columbia, Canada
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Affiliation(s)
- Trude Basso
- Orthopedic Research Centre St. Olavs hospital Trondheim University Hospital Postbox 3250 Sluppen NO-7006 Trondheim Norway
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Gardner AW, Toh MZ, Yew KSA, Lie DTT, Chou SM. Cannulated versus non-cannulated cancellous screw fixation for femoral neck fractures: a synthetic bone biomechanical study. J Orthop Surg (Hong Kong) 2015; 23:41-6. [PMID: 25920642 DOI: 10.1177/230949901502300110] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To compare the compressive strength of cannulated versus non-cannulated cancellous screws for undisplaced femoral neck fractures in synthetic bones. METHODS 18 synthetic proximal femurs simulating an AO B1 valgus impacted femoral neck fracture in osteoporotic bone were used. The fracture angles were between 55º and 63º (Pauwels grade 2). Fixation was made using 6.5-mm non-cannulated screws (n=6), 6.5-mm cannulated screws (n=6), or 7.3-mm cannulated screws (n=6). A custom-built jig was designed to guide the insertion of the screws in an identical triangular configuration. Screws were tightened by a single operator using a torque-measuring screwdriver. The femoral head was subjected to progressive axial loading at 5 mm/min. The load to failure and displacement were recorded. RESULTS The 3 groups did not differ significantly except that the load to failure was higher in the construct with 6.5-mm non-cannulated screws than that with 6.5-mm cannulated screws (1222 N vs 1008 N, p=0.003). CONCLUSION The compressive strength of a synthetic bone hip fracture model fixed with non-cannulated screws was higher than that of cannulated screws of the same diameter.
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Affiliation(s)
- A W Gardner
- Department of Orthopaedic Surgery, Jurong Health Services, Alexandra Hospital, Singapore
| | - M Z Toh
- School of Mechanical and Aerospace Engineering, Nanyang Technological University, Singapore
| | - K S A Yew
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - D T T Lie
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - S M Chou
- School of Mechanical and Aerospace Engineering, Nanyang Technological University, Singapore
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Hoshino CM, O'Toole RV. Fixed angle devices versus multiple cancellous screws: what does the evidence tell us? Injury 2015; 46:474-7. [PMID: 25655212 DOI: 10.1016/j.injury.2014.12.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 12/02/2014] [Accepted: 12/04/2014] [Indexed: 02/02/2023]
Abstract
Complications, including nonunion and avascular necrosis, are relatively common after internal fixation of a femoral neck fracture. Young patients are particularly impacted by these complications as salvage options often result in a suboptimal functional result. The quality of reduction appears to be of primary importance; however, it is unknown whether the choice of internal fixation affects the incidence of complications. In this article, we present the rationale and evidence for available internal fixation options. Current evidence is insufficient to recommend an optimal method of internal fixation, and this review demonstrates the need for high-quality randomised, controlled trials to study this problem.
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Affiliation(s)
- C Max Hoshino
- Department of Orthopaedics, Harbor-UCLA Medical Center, 1000 W. Carson St, Box 422, Torrance, CA 90509, United States.
| | - Robert V O'Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 South Greene St, T3R62, Baltimore, MD 21201, United States
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Biomechanical analysis of augmented plate fixation for the treatment of vertical shear femoral neck fractures. J Orthop Trauma 2015; 29:144-50. [PMID: 25072287 DOI: 10.1097/bot.0000000000000205] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare the strength of augmented versus nonaugmented fixation techniques for stabilizing vertical shear femoral neck fractures. METHODS Two surgical screw constructs were tested with and without augmentation using 40 composite femurs: (1) 7.3-mm cannulated screws placed in an inverted triangular configuration and (2) 135-degree dynamic hip screw (DHS). The augmentation consisted of a 2.7-mm locking plate placed on the anterior-inferior femoral neck. Specimens in all 4 groups were tested with load to failure, while failure loads, energy absorbed to failure, and axial stiffness were determined. These data were then analyzed using a two-way (construct × augmentation) analysis of variance. RESULTS There was no statistically significant interaction between screw construct and augmentation for load to failure (P = 0.11). Augmentation with the 2.7-mm locking plate increased failure loads in both constructs on average by 83% (2409 vs. 4417 N, P < 0.01). Femurs instrumented with cannulated screws had 26% higher loads to failure than those instrumented with DHS (3879 vs. 3087 N, P < 0.01). On average, the augmentation increased energy absorbed to failure by 183% and constructs' stiffness by 35%. CONCLUSIONS The strength of surgical repairs of the vertical shear femoral neck fractures can be significantly augmented with the 2.7-mm locking plate. The construct with the cannulated screws was significantly stronger than the DHS construct.
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Filipov O, Gueorguiev B. Unique stability of femoral neck fractures treated with the novel biplane double-supported screw fixation method: a biomechanical cadaver study. Injury 2015; 46:218-26. [PMID: 25527457 DOI: 10.1016/j.injury.2014.11.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2014] [Revised: 10/27/2014] [Accepted: 11/17/2014] [Indexed: 02/02/2023]
Abstract
UNLABELLED Osteosynthesis of femoral neck fractures is related to 20-46% complication rate. Filipov's novel method for biplane double-supported screw fixation (BDSF), using three cannulated screws, has demonstrated excellent clinical results since 2007. Its two calcar-buttressed screws are oriented in different coronal inclinations with steeper angles to the diaphyseal axis and intended to provide constant fixation strength under different loading situations. The aim of this study was to biomechanically evaluate BDSF fixation strength and compare it with the conventional fixation (CFIX) using three parallel cannulated screws. METHODS Eight fresh-frozen and six embalmed human femoral pairs with simulated AO/OTA31-B2.2 fracture were fixed applying either CFIX or BDSF. Quasistatic tests were performed in anteroposterior (AP) bending, followed by axial quasistatic, cyclic and destructive quasistatic tests run in 10° flexion with 7° or 16° varus specimen inclination. RESULTS Initial axial stiffness was significantly higher for BDSF in comparison with CFIX at 7° inclination (p=0.02) and not significantly different between BDSF and CFIX at 16° inclination. Compared with the intact state, it decreased significantly at 7° inclination only for CFIX (p=0.01), but not for BDSF. Interfragmentary displacement during cyclic testing was significantly smaller for BDSF than CFIX at 7° inclination (p≤0.04) and not significantly different between BDSF and CFIX at 16° inclination. Failure load did not differ significantly between BDSF and CFIX at both inclinations. CONCLUSIONS Femoral neck fracture stability can be substantially increased applying BDSF due to better cortical screw support and screw orientation. Having two calcar-buttressed screws oriented in different inclinations, BDSF can enhance constant stability during various patient activities. The more unstable the situation, the better BDSF stability is in comparison to CFIX.
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Affiliation(s)
- Orlin Filipov
- Vitosha Hospital, Simeonovsko Shose Str. 108-B, 1700 Sofia, Bulgaria.
| | - Boyko Gueorguiev
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland
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Pauyo T, Drager J, Albers A, Harvey EJ. Management of femoral neck fractures in the young patient: A critical analysis review. World J Orthop 2014; 5:204-217. [PMID: 25035822 PMCID: PMC4095012 DOI: 10.5312/wjo.v5.i3.204] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Revised: 04/17/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
Femoral neck fractures account for nearly half of all hip fractures with the vast majority occurring in elderly patients after simple falls. Currently there may be sufficient evidence to support the routine use of hip replacement surgery for low demand elderly patients in all but non-displaced and valgus impacted femoral neck fractures. However, for the physiologically young patients, preservation of the natural hip anatomy and mechanics is a priority in management because of their high functional demands. The biomechanical challenges of femoral neck fixation and the vulnerability of the femoral head blood supply lead to a high incidence of non-union and osteonecrosis of the femoral head after internal fixation of displaced femoral neck fractures. Anatomic reduction and stable internal fixation are essentials in achieving the goals of treatment in this young patient population. Furthermore, other management variables such as surgical timing, the role of capsulotomy and the choice of implant for fixation remain controversial. This review will focus both on the demographics and injury profile of young patients with femoral neck fractures and the current evidence behind the surgical management of these injuries as well as their major secondary complications.
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Fixation using alternative implants for the treatment of hip fractures (FAITH): design and rationale for a multi-centre randomized trial comparing sliding hip screws and cancellous screws on revision surgery rates and quality of life in the treatment of femoral neck fractures. BMC Musculoskelet Disord 2014; 15:219. [PMID: 24965132 PMCID: PMC4230242 DOI: 10.1186/1471-2474-15-219] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 06/18/2014] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Hip fractures are a common type of fragility fracture that afflict 293,000 Americans (over 5,000 per week) and 35,000 Canadians (over 670 per week) annually. Despite the large population impact the optimal fixation technique for low energy femoral neck fractures remains controversial. The primary objective of the FAITH study is to assess the impact of cancellous screw fixation versus sliding hip screws on rates of revision surgery at 24 months in individuals with femoral neck fractures. The secondary objective is to determine the impact on health-related quality of life, functional outcomes, health state utilities, fracture healing, mortality and fracture-related adverse events. METHODS/DESIGN FAITH is a multi-centre, multi-national randomized controlled trial utilizing minimization to determine patient allocation. Surgeons in North America, Europe, Australia, and Asia will recruit a total of at least 1,000 patients with low-energy femoral neck fractures. Using central randomization, patients will be allocated to receive surgical treatment with cancellous screws or a sliding hip screw. Patient outcomes will be assessed at one week (baseline), 10 weeks, 6, 12, 18, and 24 months post initial fixation. We will independently adjudicate revision surgery and complications within 24 months of the initial fixation. Outcome analysis will be performed using a Cox proportional hazards model and likelihood ratio test. DISCUSSION This study represents major international efforts to definitively resolve the treatment of low-energy femoral neck fractures. This trial will not only change current Orthopaedic practice, but will also set a benchmark for the conduct of future Orthopaedic trials. TRIAL REGISTRATION The FAITH trial is registered at ClinicalTrials.gov (Identifier NCT00761813).
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Satish BRJ, Ranganadham AV, Ramalingam K, Tripathy SK. Author's reply. Indian J Orthop 2014; 48:229-231. [PMID: 24741152 PMCID: PMC3977386 DOI: 10.4103/0019-5413.128780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Bhava RJ Satish
- Department of Orthopedic Surgery, BRJ Ortho Centre, Coimbatore, Tamil Nadu, India
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Basler SE, Traxler J, Müller R, van Lenthe GH. Peri-implant bone microstructure determines dynamic implant cut-out. Med Eng Phys 2013; 35:1442-9. [DOI: 10.1016/j.medengphy.2013.03.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Revised: 01/20/2013] [Accepted: 03/27/2013] [Indexed: 10/26/2022]
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Makki D, Mohamed AM, Gadiyar R, Patterson M. Addition of an anti-rotation screw to the dynamic hip screw for femoral neck fractures. Orthopedics 2013; 36:e865-8. [PMID: 23823042 DOI: 10.3928/01477447-20130624-15] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The authors investigated the use of an anti-rotation screw with the dynamic hip screw (DHS) during internal fixation of Garden I and II femoral neck fractures. Sixty-five patients with Garden I and II femoral neck fractures (mean age, 70 years) were treated with internal fixation at the authors' institution. In 31 patients, a 2-hole DHS was used alone (group 1), and in 34 patients, the DHS was combined with an anti-rotation screw placed in the cranial part of femoral head and neck (group 2). Patients' preinjury function and mental level were assessed using the Barthel index and the Abbreviated Mental test, respectively. The outcome measures included cost implications, operative time, and intraoperative radiation dose. The modified Harris Hip Score and a radiological assessment were performed at a mean of 11 months (range, 8-24 months) postoperatively. The use of the anti-rotation screw was associated with a longer operative time (mean, 44.54 minutes in group 1 vs 51.52 minutes in group 2; P<.0001) and more fluoroscopy screening (mean dose area product, 28.39 cGy/cm(2) in group 1 vs 44.33 cGy/cm(2) in group 2; P=.03). The additional cost of using an anti-rotation screw was £106 ($170) per case. No difference existed between the 2 groups with regard to radiological union, onset of avascular necrosis, and rate of revision surgeries. An anti-rotation screw, used with the dynamic hip screw, involves extra costs, prolongs operative time, and requires more intraoperative fluoroscopy screening but offers no advantages with regard to fracture union.
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Affiliation(s)
- Daoud Makki
- Department of Trauma and Orthopaedics, Royal Sussex County Hospital, Brighton and University Hospitals NHS Trust, Eastern Road, Brighton BN2 5BE, United Kingdom.
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Matityahu A, Hurschler C, Badenhop M, Stukenborg-Colsman C, Waizy H, Wentz B, Marmor M, Krettek C. Reduction of pullout strength caused by reinsertion of 3.5-mm cortical screws. J Orthop Trauma 2013; 27:170-6. [PMID: 22534691 DOI: 10.1097/bot.0b013e31825490b1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Osteosynthesis of the tibia, tibial plafond, and calcaneus is commonly performed with plates and 3.5-mm self-tapping cortical screws. Screw insertion and reinsertion within the same hole in the bone may occur during surgery. Therefore, the purpose of this study was to evaluate the pullout strength of 3.5-mm self-tapping screws with up to 5 re-insertions in the diaphysis of the tibia, metaphysis of the distal tibia, calcaneus, and a polyurethane synthetic bone model. METHODS Screws were inserted into a synthetic bone model and 5 pairs of human cadaveric diaphyseal tibiae, distal tibiae, and calcanei. The bone was predrilled, and then 3.5-mm cortical self-tapping 316 L stainless steel screws with a washer were inserted bicortically. Screws were inserted from 1 to 5 times at each location. The screws were grasped and subjected to 5-mm/min tensional force via the biaxial material testing systems machine. Statistical significance was determined using a paired 2-tailed t test. RESULTS There was a significant difference in the pullout strength of the tibial diaphysis (1710 ± 550 N), tibial metaphysis (471 ± 266 N), and calcaneus (238 ± 90 N; P < 0.01). The tibial diaphysis pullout strength was 1710 ± 550 N for one insertion differing significantly relative to the groups with 4 (average 1030 ± 543 N, P = 0.004) or 5 (average 364 ± 209 N, P < 0.001) insertions. The tibial metaphyseal pullout strength for the single insertion group was 471 ± 266 N and differed significantly relative to the 3 (P = 0.026), 4 (P = 0.044), and 5 (P = 0.042) insertion groups. The calcaneal pullout strength for the single insertion group was 238 ± 90 N with a significant difference of the 1, 3, and 4, versus the 5 insertion group (P = 0.027, 0.040, and 0.033, respectively). The synthetic bone model pullout strength decreased significantly from the one insertion group relative to all other insertion groups (group 1, 1167 ± 263 N; group 2, 768 ± 199 N; group 3, 694 ± 295 N; group 4, 662 ± 356 N; and group 5, 154 ± 183 N; P < 0.02). CONCLUSIONS There is a significant decrease in relative pullout strength of 3.5-mm self-tapping cortical screws when comparing the tibial diaphysis, tibial metaphysis, and calcaneus. There is also a significant decrease in 3.5-mm self-tapping screw pullout strength after repeated reinsertions in the synthetic bone model, mid-shaft tibia, metaphyseal tibia, and calcaneus. We recommend that during osteosynthesis, careful screw insertion, and minimal reinsertion be performed.
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Affiliation(s)
- Amir Matityahu
- Department of Orthopaedic Surgery, UCSF/SFGH Orthopaedic Trauma Institute, San Francisco, CA 94110, USA.
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Yang JJ, Lin LC, Chao KH, Chuang SY, Wu CC, Yeh TT, Lian YT. Risk factors for nonunion in patients with intracapsular femoral neck fractures treated with three cannulated screws placed in either a triangle or an inverted triangle configuration. J Bone Joint Surg Am 2013; 95:61-9. [PMID: 23283374 DOI: 10.2106/jbjs.k.01081] [Citation(s) in RCA: 140] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Intracapsular femoral neck fractures are associated with high rates of nonunion. We aimed to identify risk factors for nonunion in patients with both displaced and nondisplaced intracapsular femoral neck fractures treated with three 7-mm parallel cannulated screws, placed in either a triangle or an inverted triangle configuration, using failure of fixation as the primary outcome. METHODS Clinical and radiographic data for patients with intracapsular femoral neck fractures treated with either triangle fixation (one proximal screw and two distal screws) or inverted triangle fixation (two proximal screws and one distal screw), between January 1, 2000, and July 30, 2009, were analyzed. RESULTS A total of 202 patients, seventy-six men and 126 women with an average age (and standard deviation) of 64.53 ± 15.81 years (range, nineteen to ninety-three years), were included in the analysis. Union occurred in 158 patients, and nonunion occurred in forty-four. There were no differences between the union and nonunion groups with respect to age, sex, fracture side, fracture angle, fracture level, or estimated bone density. There were significant differences in fracture type, fixation configuration, reduction quality, and screw-tip subchondral purchase between patients with and without union. The estimated odds ratio for fracture nonunion was 2.93 (95% confidence interval [CI], 1.08, 7.96) in subjects with displaced fractures compared with those without displaced fractures (p = 0.035), 18.92 (95% CI, 1.91, 187.09) in subjects with borderline and unacceptable reduction compared with those with anatomic reduction (p = 0.012), and 2.92 (95% CI, 1.27, 6.69) for internal fixation with a triangle configuration compared with fixation with an inverted triangle configuration (p = 0.010). CONCLUSIONS Screw fixation with a triangle configuration, a displaced fracture, and poor reduction are risk factors for nonunion in intracapsular femoral neck fractures treated with fixation with multiple screws.
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Affiliation(s)
- Jui-Jung Yang
- Department of Orthopedics, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
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Biomechanical analysis of a novel femoral neck locking plate for treatment of vertical shear Pauwel's type C femoral neck fractures. Injury 2012; 43:802-6. [PMID: 22019259 DOI: 10.1016/j.injury.2011.09.012] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2011] [Revised: 09/09/2011] [Accepted: 09/12/2011] [Indexed: 02/02/2023]
Abstract
BACKGROUND The purpose of this study is to determine the biomechanical stability of a novel prototype femoral neck locking plate (FNLP) for treatment of Pauwels type C femoral neck fractures compared with other current fixation methods. METHODS Forty femur sawbones were divided into groups and a vertical femoral neck fracture was made. Each group was repaired with one of the following: (CS) three parallel cancellous screws; (XCS) two cancellous lag screws into the head and one transverse lag screw into the calcar; and (FNLP) a novel FNLP with two 5.7 mm locking, one lag screw into the calcar and two screws into the shaft; and (AMBI) a two-hole, 135° AMBI plate with a derotation screw. All groups were tested for change in axial stiffness over 20000 cycles, and rotational stiffness was measured before and after cyclic testing. A maximum load to failure test was also conducted. Results were compared with one-way analysis of variance (ANOVA) and Fisher protected least significant difference (PLSD). RESULTS Results for axial stiffness show that AMBI, CS, XCS and FNLP are 2779.0, 2207.2, 3029.9 and 3210.7 N-m mm(-1), respectively. Rotational rigidity results are 4.5, 4.1, 17.1 and 18.7 N-m mm(-1). The average cyclic displacements were 0.75, 0.88, 0.80 and 0.65 mm, respectively. Destructive failure loads for AMBI, CS, XCS and FNLP were 2.3, 1.7, 1.6 and 1.9 kN, respectively. CONCLUSIONS The results of this experiment show statistically significant increases in axial stiffness for the FNLP compared with three traditional fixation methods. The FNLP demonstrates increased mechanical stiffness and combines the desirable features of current fixation methods.
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Mittal R, Banerjee S. Proximal femoral fractures: Principles of management and review of literature. J Clin Orthop Trauma 2012; 3:15-23. [PMID: 25983451 PMCID: PMC3872791 DOI: 10.1016/j.jcot.2012.04.001] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Accepted: 04/18/2012] [Indexed: 01/14/2023] Open
Abstract
UNLABELLED The purpose of this study was to review the principles involved in the management of proximal femoral fractures as reported in the literature. METHODS A medical literature search in the MEDLINE (PubMed) and Cochrane database was undertaken to review strategies and principles in proximal femoral fracture treatment. Randomized control trials and meta analysis were given preference while case reports/small series were rejected. RESULTS AND CONCLUSIONS Early anatomical reduction and surgical fixation remains the best option to reduce the risk of complications like non-union and avascular necrosis in treating fracture neck femurs. Cancellous screws continue to be the preferred treatment for fixation of neck femur fractures in younger population until the benefit of using sliding hip screws is validated by large multicentric studies. In the geriatric age group, early prosthetic replacement brings down the mortality and morbidity associated with neck femur fractures. Sliding hip screw (DHS) is the best available option for stable inter trochanteric fractures. The use of intramedullary nails e.g. PFN is beneficial in treating inter trochanteric fractures with comminution and loss of lateral buttress. Intramedullary implants have been proven to have increased success rates in subtrochanteric fractures and should be preferred over extramedullary plate fixation systems.
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Affiliation(s)
- Ravi Mittal
- Additional Professor, Dept. of Orthopedics, All India Institute of Medical Sciences (A.I.I.M.S.), New Delhi, India
| | - Sumit Banerjee
- Senior Resident, Dept. of Orthopedics, All India Institute of Medical Sciences (A.I.I.M.S.), New Delhi, India
- Corresponding author. Tel.: +91 9910895314.
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Hwang JH, Garg AK, Oh JK, Oh CW, Lee SJ, Myung-Rae C, Kim MK, Kim H. A biomechanical evaluation of proximal femoral nail antirotation with respect to helical blade position in femoral head: A cadaveric study. Indian J Orthop 2012; 46:627-32. [PMID: 23325963 PMCID: PMC3543878 DOI: 10.4103/0019-5413.104186] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Despite new developments in the management of osteoporotic fractures, complications like screw cutout are still found in the fixation of proximal femur fractures even with biomechanically proven better implants like proximal femoral nail antirotation (PFNA). The purpose of this cadaveric study was to investigate the biomechanical stability of this device in relation to two common positions (center-center and inferior-center) of the helical blade in the femoral head in unstable trochanteric fractures. MATERIALS AND METHODS Eight pairs of human cadaveric femurs were used; in one group [center-center (C-C) group], the helical blade of PFNA was fixed randomly in central position both in anteroposterior and lateral view, whereas in the other group it was fixed in inferior one-third position in anteroposterior and in central position in lateral view [inferior-center (I-C) group]. Unstable intertrochanteric fracture was created and each specimen was loaded cyclically till load to failure RESULTS Angular and rotational displacements were significantly higher within the C-C group compared to the I-C group in both unloaded and loaded condition. Loading to failure was higher in the I-C group compared to the C-C group. No statistical significance was found for this parameter. Correlations between tip apex distance, cyclic loading which lead to femoral head displacement, and ultimate load to failure showed a significant positive relationship. CONCLUSION The I-C group was superior to the C-C group and provided better biomechanical stability for angular and rotational displacement. This study would be a stimulus for further experimental studies with larger number specimens and complex loading protocols at multicentres.
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Affiliation(s)
- Jin-Ho Hwang
- Department of Orthopaedic Surgery, Konkuk University School of Medicine, Seoul, Korea
| | - Anant Kumar Garg
- Department of Orthopedic Surgery, Korea University Guro Hospital, Seoul, Korea,Address for correspondence: Dr. Anant Kumar Garg, Fellow, Department of Orthopedic Surgery Korea University Guro Hospital, 97, Gurodong-Gil Guro-Gu 152-703, Republic of Korea, E-mail:
| | - Jong-Keon Oh
- Department of Orthopedic Surgery, Korea University Guro Hospital, Seoul, Korea
| | - Chang-Wug Oh
- Department of Orthopaedic Surgery, Kyungpook National University Hospital, Daegu, Korea
| | - Sung-Jae Lee
- Department of Biomedical Engineering, Inje University, Gyoungnam, Gimhae, Korea
| | - Cho Myung-Rae
- Department of Biomedical Engineering, Inje University, Gyoungnam, Gimhae, Korea
| | - Min-Keun Kim
- Department of Orthopaedic Surgery, Konkuk University School of Medicine, Seoul, Korea
| | - Hyun Kim
- Department of Biomedical Engineering, Inje University, Gyoungnam, Gimhae, Korea
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Biomechanical evaluation of bone-cement augmented Proximal Femoral Nail Antirotation blades in a polyurethane foam model with low density. Clin Biomech (Bristol, Avon) 2012; 27:71-6. [PMID: 21824697 DOI: 10.1016/j.clinbiomech.2011.07.006] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Revised: 06/14/2011] [Accepted: 07/12/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Helically shaped cephalic implants have proven their benefit to provide an improved stabilization of unstable hip fractures. However, cut out ratios up to 3.6% still occur. This in vitro study evaluated the biomechanical performance of a novel cement augmentation technique of the Proximal Femoral Nail Antirotation in surrogate femora. METHODS Four study groups were formed out of 24 polyurethane foam specimens with low density. Proximal Femoral Nail Antirotation blades were implanted, either non-augmented, or augmented using 3ml of injectable Polymethylmethacrylate bone-cement. The influence of implant mal-positioning was investigated by placing the blade either centered in the femoral head or off-centric in an anteroposterior direction. All specimens underwent cyclic loading under physiological conditions. Starting at 1000 N, the load was monotonically increased by 0.1N/cycle until construct failure. Movement of the head was identified by means of optical motion tracking. Non-parametric test statistics were carried out on the cycles to failure, to compare between study groups. FINDINGS Compared to control samples; augmented samples showed a significantly increased number of cycles to failure (P=0.012). In the groups with centric position of the Proximal Femoral Nail Antirotation blade, cement augmentation led to an increase in loading cycles of 225%. In the groups with off-centric positioning of the blade, this difference was even more accentuated (933%). INTERPRETATION Cement augmentation of the Proximal Femoral Nail Antirotation blade with small amounts of bone-cement for treatment of osteoporotic hip fractures clearly enhances fixation stability and carries high potential for clinical application.
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Abstract
OBJECTIVE To evaluate the outcomes of displaced intracapsular femoral neck fractures treated with a cephalomedullary device. DESIGN Retrospective study. SETTING Level I trauma center. PATIENTS Between 2002 and 2008, 18 patients with displaced intracapsular femoral neck fractures were treated at our Level I trauma center with a cephalomedullary nail. There were 12 males and six females. Six patients were younger than 60 years of age with a mean age of 63 years (range, 40-88 years). Thirteen fractures were midcervical (Orthopaedic Trauma Association [OTA] 31-B2.2 and B2.3), and five fractures were subcapital (OTA 31-B3). Patients with basicervical fractures (OTA 31-B2.1) and nondisplaced subcapital fractures (OTA 31-B1) were excluded. INTERVENTION All patients underwent cephalomedullary nail fixation of their femoral neck fractures under the supervision of fellowship-trained orthopaedic trauma surgeons. MAIN OUTCOME MEASUREMENTS Postoperative radiographs were evaluated for fracture reduction quality. Clinical follow-up was available on 13 patients with a minimum of 12 months (range, 12-25 months). A radiographic and chart review was done to identify complications and outcomes. RESULTS Seven of eight fractures that healed were anatomically reduced. No failures occurred in the six patients younger than 60 years. Fixation failed in five of 13 fractures (38.4%) with varus collapse as the typical failure mode. The mean time to failure in these cases was 3.8 months (range, 1-7 months). Overall, the failure rate for the subcapital fractures was 100% (three of three) and for midcervical 20% (two of 10) with all failures being in patients older than 60 years (71.4%). Osteonecrosis without fixation failure or cutout occurred in one case. CONCLUSION Cephalomedullary nail fixation of displaced intracapsular femoral neck fractures demonstrated mixed results. For younger patients with midcervical fractures that were well reduced, the fixation performed well. Displaced subcapital fractures in patients older than 60 years demonstrated a 100% failure rate. As a result, we cannot advocate cephalomedullary fixation for displaced intracapsular femoral neck fractures in patients older than 60 years, although in younger patients, these implants may provide an alternative to side-plate based fixation devices.
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A Comparative Biomechanical Analysis of Fixation Devices for Unstable Femoral Neck Fractures: The Intertan Versus Cannulated Screws or a Dynamic Hip Screw. ACTA ACUST UNITED AC 2011; 71:625-34. [DOI: 10.1097/ta.0b013e31820e86e6] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Johanson NA, Litrenta J, Zampini JM, Kleinbart F, Goldman HM. Surgical treatment options in patients with impaired bone quality. Clin Orthop Relat Res 2011; 469:2237-47. [PMID: 21384210 PMCID: PMC3126955 DOI: 10.1007/s11999-011-1838-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Bone quality should play an important role in decision-making for orthopaedic treatment options, implant selection, and affect ultimate surgical outcomes. The development of decision-making tools, currently typified by clinical guidelines, is highly dependent on the precise definition of the term(s) and the appropriate design of basic and clinical studies. This review was performed to determine the extent to which the issue of bone quality has been subjected to this type of process. QUESTIONS/PURPOSES We address the following issues: (1) current methods of clinically assessing bone quality; (2) emerging technologies; (3) how bone quality connects with surgical decision-making and the ultimate surgical outcome; and (4) gaps in knowledge that need to be closed to better characterize bone quality for more relevance to clinical decision-making. METHODS PubMed was used to identify selected papers relevant to our discussion. Additional sources were found using the references cited by identified papers. RESULTS Bone mineral density remains the most commonly validated clinical reference; however, it has had limited specificity for surgical decision-making. Other structural and geometric measures have not yet received enough study to provide definitive clinical applicability. A major gap remains between the basic research agenda for understanding bone quality and the transfer of these concepts to evidence-based practice. CONCLUSIONS Basic bone quality needs better definition through the systematic study of emerging technologies that offer a more precise clinical characterization of bone. Collaboration between basic scientists and clinicians needs to improve to facilitate the development of key questions for sound clinical studies.
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Affiliation(s)
- Norman A. Johanson
- Department of Orthopaedic Surgery, Drexel University College of Medicine, 245 N 15th Street, MS 420, Philadelphia, PA 19102 USA
| | - Jody Litrenta
- Drexel University College of Medicine, Philadelphia, PA USA
| | - Jay M. Zampini
- Department of Orthopaedic Surgery, Drexel University College of Medicine, 245 N 15th Street, MS 420, Philadelphia, PA 19102 USA
| | - Frederic Kleinbart
- Department of Orthopaedic Surgery, Drexel University College of Medicine, 245 N 15th Street, MS 420, Philadelphia, PA 19102 USA
| | - Haviva M. Goldman
- Department of Orthopaedic Surgery, Drexel University College of Medicine, 245 N 15th Street, MS 420, Philadelphia, PA 19102 USA ,Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA USA
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Su Y, Chen W, Zhang Q, Li B, Li Z, Guo M, Pan J, Zhang Y. An irreducible variant of femoral neck fracture: a minimally traumatic reduction technique. Injury 2011; 42:140-5. [PMID: 20570257 DOI: 10.1016/j.injury.2010.05.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2010] [Revised: 04/20/2010] [Accepted: 05/03/2010] [Indexed: 02/02/2023]
Abstract
We present 25 cases of irreducible variant femoral neck fractures that require surgical management after routine manipulative manoeuvre attempts have failed. In our study, an irreducible variant of femoral neck fractures is defined as a reduction that cannot be achieved after multiple attempts at closed reduction. This was evident radiographically, as seen in displaced–impacted femoral neck fractures when the proximal femur compacts and rotates along with the distal part, and anatomical reduction cannot be achieved with manipulative manoeuvres. Another rare situation also included is when the proximal fragment disconnects from the femur and dislocates as a ‘floating’ component, consequently resulting in failure of alignment of the distal fragment to the proximal femur.Here, we describe a technique, applied as a minimally traumatic procedure to achieve anatomic reduction in such cases. With the patient placed in supine position on the fracture table under general anaesthesia, the injury site is exposed and the procedure performed under intra-operative radiographic control. Location of the femoral artery is done first by palpation. The insertion site of the K-wires or Steinman pins on the proximal thigh is 1.5–3 cm lateral to the femoral artery. The K-wires or Steinmanpins are inserted vertically into the middle 1/2–2/3 of the femoral head and more than 1 cm inferior to the sub-chondral bone of the femoral head to a depth of approximately, 1/2 diameter of the femoral head. The pins are then used as a joystick to control the movement of the proximal femur. With the help of the K-wires, surgeons can manually control the movement of the proximal femur and ensure anatomic reduction with the distal fragment using routine-closed reduction. Three cannulated screws are used to stabilise the fracture after anatomic reduction is achieved and maintained in a stable position. All cases were treated with this minimally invasive procedure and internal fixation, 25 fractures united,uneventfully, whilst two of them developed femoral head necrosis at 10 months and 4.5 years postoperatively, respectively.
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Affiliation(s)
- Yanling Su
- Department of Orthopaedics, 3rd Hospital, Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, Hebei 050051, PR China
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Mukherjee P, Ashworth MJ. A new device to treat intra-capsular fracture neck of femur non-union. Strategies Trauma Limb Reconstr 2010; 5:159-62. [PMID: 21286362 PMCID: PMC2994626 DOI: 10.1007/s11751-010-0096-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2009] [Accepted: 09/13/2010] [Indexed: 11/29/2022] Open
Abstract
In adolescents and young adults, femoral neck fractures often result from high-velocity trauma. These fractures are usually of vertical shear pattern. There is an increased incidence of avascular necrosis and non-union, which is difficult to treat. Non-union of fractured neck of femur in young adults is a serious problem. There is growing evidence that these fractures should be treated with an angle-stable device to improve biomechanics at the fracture site. An ideal implant should prevent varus deformation and retroversion of the fracture in order to prevent failure of the osteosynthesis and thus preventing cut-out of implant and non-union at the fracture site. We report the first use of an Orthofix Gottfried Percutaneous Compression Plate (PC.C.P.) (Orthofix, Guilford, UK) to treat a non-union of an intra-capsular fractured neck of femur. We recommend this, in combination with autologous bone grafting, via a mini hip modification of the Smith-Petersen approach.
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Affiliation(s)
- P. Mukherjee
- Orthopaedic Surgery, Rotherham General Hospital, Rotherham, S60 2UD UK
| | - M. J. Ashworth
- Trauma and Orthopaedics, Torbay Hospital, Torquay, Devon TQ2 7AA UK
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