Addressing posterior tilt displacement during surgery to lower failure risk of sub-capital Garden types 1 and 2 femoral fractures

Steinberg, Ely L.; Albagli, Assaf; Snir, Nimrod; Salai, Moshe; Khoury, Amal; Ben‐Tov, Tomer; Factor, Shai

doi:10.1007/s00402-021-03900-5

Cited by 4 publications

(6 citation statements)

References 28 publications

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“…In addition, the treatment modality may be different depending on the tilt, and plain radiographs and computed tomography (CT) scan were evaluated simultaneously for accurate assessment of the tilt 29,30 . Tilt evaluation by X‐ray and CT was different for each individual patient, but the results were not significantly different.…”

Section: Discussionmentioning

confidence: 99%

“… 28 Tilt evaluation using computed tomography (CT) scan was additionally performed (Figure 7). 29,30 The FNS was measured on anteroposterior (AP) radiographs using the method described by Zlowodzki et al 31 The changes in the x‐axis were measured as femoral offset shortening, and the y‐axis was measured as femoral height shortening (Figure 8). The FNS was calculated using θ corresponding to the CCD angle as: z = y sin(θ) + x cos(θ), as described by Weil at el 32 …”

Section: Methodsmentioning

confidence: 99%

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Simple Minimally Invasive Method to Reduce Valgus‐Impacted and Tilted Femoral Neck Fractures without Soft Tissue or Cartilage Injury: Radiological and Clinical Results

Kweon

Song

Park

et al. 2023

Orthopaedic Surgery

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ObjectiveThis is a rare study comparing the radiological and functional outcomes of fixation after reduction with in situ fixation group using Femoral Neck System (FNS). The aim of this study was to introduce a simple, innovative, minimally invasive method to reduce valgus‐impacted and tilted femoral neck fractures without soft tissue or cartilage injury.MethodsA retrospective comparative analysis of 46 patients between May 2020 and February 2022 was performed. In the control group, 23 patients underwent in situ fixation without reduction. In the study group, another 23 patients were managed by fixation after reduction using a percutaneous pull‐out technique with a full threaded Steinmann pin. Caput‐collum‐diaphysis (CCD) angle, tilt, and femoral neck shortenings were compared between the two groups. In addition, Harris Hip Score (HHS) was evaluated and compared at 1 year after surgery. Basically, independent samples t‐test was used to compare radiological and functional results.ResultsPatients' initial valgus and tilt angles were not significantly different between the groups (n.s.). However, the CCD and tilt angles measured immediately and at one year postoperatively were significantly different between the groups (p < 0.05). Regarding femoral neck shortening, shortening in the three directions, the x, y, and z vectors, was significantly less in the reduction group immediately postoperatively and at 1 year post‐surgery (p < 0.05). The mean HHS at 1 year postoperatively was 79.7 ± 8.4 in the in situ fixation group and 87.9 ± 6.6 in the reduction groups, and there was a significant difference (p < 0.05).ConclusionThe pull‐out method with a threaded Steinmann pin to reduce valgus‐impacted and tilted femoral neck fracture is safe and effective for accomplishing anatomical restoration. This may achieve successful bone union and maintain the femoral neck length and original tilt without nearby soft tissue or cartilage injury.

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Simple Minimally Invasive Method to Reduce Valgus‐Impacted and Tilted Femoral Neck Fractures without Soft Tissue or Cartilage Injury: Radiological and Clinical Results

Kweon

Song

Park

et al. 2023

Orthopaedic Surgery

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“…Consequently, the importance of anatomical reduction has been emphasized in recent years, and several reduction techniques have been proposed. Steinberg et al 5) recommended internal rotation and traction and correction of posterior tilt by application of AP pressure on the femoral neck as necessary for reducing the fracture. A minimally invasive reduction technique using a Steinmann pin or Kirschner wire was introduced by Yoon et al 19) and Noda et al 20) .…”

Section: Discussionmentioning

confidence: 99%

“…However, several authors have recently reported poor outcomes for patients with fractures having more than 15° of valgus deformity or posterior tilt larger than 15 to 20 who underwent treatment with in situ fixation 2 3 4) . Careful reduction of the fracture has been recommended by some surgeons, including Steinberg et al 5) . Park et al 6) , who compared shortening of the femoral neck, clinical outcomes, and Harris hip score between patients treated with in situ fixation and those who had undergone closed reduction and internal fixation in severe VI-FNF, reported that the reduction group showed better overall outcomes.…”

Section: Introductionmentioning

confidence: 99%

Postoperative Valgus Deformity and Progression of Ostheoarthritis in Non-Displaced Femoral Neck Fractures

Kim,

Sung

2023

Hip & Pelvis

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Purpose Nondisplaced femoral neck fractures have traditionally been treated with in situ fixation. However, poor surgical and clinical outcomes have been reported for fractures with valgus deformity >15°, and the reduction of valgus impaction has recently been emphasized. In addition, early degenerative osteoarthritis can be caused by cam-type femoroacetabular impingement after healing of femoral neck fractures. This study was designed with the objective of confirming the difference in progression of radiographic osteoarthritis according to the severity of the valgus deformity. Materials and Methods Patients who underwent internal fixation using multiple cannulateld screws for management of nondisplaced femoral neck fractures were divided into two groups: high valgus group (postoperative valgus angle ≥15°) and low valgus group (postoperative valgus angle <15°). Evaluation of demographic data and changes in the joint space width from the immediate postoperative period to the latest follow-up was performed. Results A significant decrease in joint space width in both hip joints was observed in the high valgus group when compared with the low valgus group, including cases with an initial valgus angle less than 15° and those corrected to less than 15° of valgus by reduction. No complications requiring surgical treatment were observed in either group; however, two cases of avascular necrosis, one in each group, which developed in the low valgus group after reduction of the fracture, were followed for observation. Conclusion Performing in situ fixation in cases involving a valgus deformity ≥15° in non-displaced femoral neck fractures may cause accelerated narrowing of the hip joint space.

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“…It was concluded that most of the complications found in surgeries can be avoided by appropriate reduction of the posterior tilt ( Figure 8 ). 38 Recent three-dimensional analysis of Garden type I fractures support this sentiment. These fractures were observed to have deceivingly large measurements of displacement, calling into question the decision for nonsurgical treatment of nondisplaced FNFs.…”

Section: Introductionmentioning

confidence: 99%

Management of Garden-I and II Femoral Neck Fractures: Perspectives on Primary Arthroplasty

Olansen,

Ibrahim,

Aaron

2024

ORR

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This review compares internal fixation versus arthroplasty in the treatment of nondisplaced femoral neck fractures (FNFs) calling attention to evolving areas of consensus that influence clinical decision-making. The Garden classification system, typically dichotomized into nondisplaced (types I and II) and displaced (types III and IV) fractures, has been used as a guide for surgical decision-making. Conventionally, treatment of nondisplaced FNF in the elderly has been with internal fixation, and treatment of a displaced FNF has been hemi-, or more recently total hip, arthroplasty. Studies over the last decade have raised concern over the appropriate treatment of nondisplaced FNFs due to high rates of reoperation of nondisplaced FNFs treated with internal fixation. Avascular necrosis (AVN), failure of internal fixation, secondary malunion, and pin/nail penetration through the femoral head have all been observed. Several studies have attributed fixation failure to a degree of femoral neck tilt ≥20°, either posteriorly or anteriorly as seen on the lateral X-ray. Because of these observations of fixation failures, the suggestion has been made that arthroplasty be used when the degree of posterior tilt exceeds a threshold of ≥20° tilt with the expectation of diminishing failure of fixation, decreasing the risk of reoperation and preserving function without increasing mortality rate. Frustrating additional analyses are uncertainties over the mechanisms of failure of internal fixation with ≥20° tilt and the persistently substantial 1-year mortality rate after FNF, which has not been influenced by fixation or replacement type. Due to the lack of consensus regarding the determination of the appropriate surgical intervention for nondisplaced FNFs, an improved algorithm for surgical decision-making for these fractures may prove useful.

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Addressing posterior tilt displacement during surgery to lower failure risk of sub-capital Garden types 1 and 2 femoral fractures

Cited by 4 publications

References 28 publications

Simple Minimally Invasive Method to Reduce Valgus‐Impacted and Tilted Femoral Neck Fractures without Soft Tissue or Cartilage Injury: Radiological and Clinical Results

Simple Minimally Invasive Method to Reduce Valgus‐Impacted and Tilted Femoral Neck Fractures without Soft Tissue or Cartilage Injury: Radiological and Clinical Results

Postoperative Valgus Deformity and Progression of Ostheoarthritis in Non-Displaced Femoral Neck Fractures

Management of Garden-I and II Femoral Neck Fractures: Perspectives on Primary Arthroplasty

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