Is non-operative treatment still relevant for Garden Type I fractures in elderly patients? The femoral neck impaction angle as a new CT parameter for determining the indications of non-operative treatment

Hardy, Jérémy; Collin, Camille; Mathieu, Pierre-Alain; Vergnenegre, Guillaume; Charissoux, J.-L.; Marcheix, Pierre-Sylvain

doi:10.1016/j.otsr.2018.12.010

Cited by 9 publications

(3 citation statements)

References 16 publications

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“…Studies have found that the rate of femoral head necrosis, fracture redisplacement rate, and fracture nonunion rate are higher after nonsurgical treatment of Garden I fracture [ 23 ]. Based on the results of this study, we believe that patients with Garden I fractures cannot achieve effective reduction of fractures either conservatively or with in situ fixation surgery [ 24 , 25 ].…”

Section: Discussionmentioning

confidence: 99%

A three-dimensional measurement study of fracture displacement in Garden I femoral neck fracture: a retrospective study

Wang

Bai

et al. 2023

BMC Musculoskelet Disord

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Background Garden I femoral neck fractures are nondisplaced femoral neck fractures. Nonoperative treatment and in situ fixation are the preferred treatments. However, the postoperative outcome is not satisfactory and the incidence of complications remains high, which raises doubts about the accuracy of the diagnosis of nondisplaced Garden I fractures. Recently, three-dimensional (3D) reconstruction has been reported as a mature technology for reconstructing the bone structure of patients. We further extended this technique in the measurement of the fracture spatial displacement to verify the accuracy of Garden I femoral neck fractures. Methods This was a retrospective study of patients with Garden I femoral neck fractures from January 2013 to December 2018 at our institution, who were included according to specified criteria. A bilateral proximal femur model of each patient was established based on computed tomography (CT) data. The displacement of the deepest portion of the femoral head fovea, the displacement of the center of the femoral head and the rotation of the femoral head were measured in the bilateral model. Results A total of 102 patients diagnosed with Garden I fractures were included in this study. The cohort included 32 men and 70 women, with an average age of 55.88 ± 15.32 years. In these patients, the average displacement of the deepest portion of the femoral head fovea was 16.43 ± 7.69 mm. The minimum and maximum displacement was 3.58 and 44.32 mm, respectively. The average displacement of the center of the femoral head was 10.39 ± 5.47 mm and ranged from 2.16 to 34.42 mm. The rotational angle was 23.81 ± 10.15 ° and ranged from 3.71 ° to 61.19 °. Conclusions Garden I fractures have large spatial displacement and cannot be considered incomplete or nondisplaced fractures. Therefore, we suggest that anatomical reduction should be considered during treatment.

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Section: Discussionmentioning

confidence: 99%

A three-dimensional measurement study of fracture displacement in Garden I femoral neck fracture: a retrospective study

Wang

Bai

et al. 2023

BMC Musculoskelet Disord

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“…Those patients without an impacted femoral neck fracture are prone to have a slip of the fracture by further weight bearing [15,16]. Furthermore, we recommend that patients with an impacted femoral neck fracture, specially Garden types 1 to be treated conservatively from the beginning regardless of the health status and age of the patient [17][18][19][20]. However, biomechanical studies have confirmed that fracture fixation and immobilization affect the pattern of skeletogenic stem cell differentiation into osteoblasts; mechanical fixation will obviously influence neovascularisation [11,12,21] that could be simulated in the impaction of the fracture in those treated conservatively with further compression and fixation as seen in Garden type 1 femoral neck fracture.…”

Section: Discussionmentioning

confidence: 99%

Challenging the dogma to “always operate” acute hip fractures: a proof-of-concept pilot study for nonoperative management of undisplaced femoral neck fractures

et al. 2022

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Background The notion that all acute hip fractures are a surgical entity requiring either surgical fracture fixation or hip replacement represents a historic dogma, particularly within the orthopaedic community of the United States. The present study from a European regional trauma center was designed to challenge the notion that stable and undisplaced femoral neck fractures represent an absolute indication for surgical management. Methods The purpose of this study was to investigate the hypothesis that stable and undisplaced femoral neck fractures of the Garden types 1 and 2 can be safely managed nonoperatively. A retrospective observational cohort study was carried out at a regional orthopaedic trauma center in Germany from January 1, 2016 to June 30, 2021. The inclusion criteria specified patients older than 18 years suffering a < 24 h, traumatic, femoral neck fracture Garden types 1 and 2. Exclusion criteria included Garden types 3 and 4 femoral neck fractures, pregnancy, active infection or previous surgery, tumor-associated fractures, medical history of femoral neck necrosis, vascular injury associated with femoral neck fractures, nerve injury associated to a femoral neck fracture and ≥ 24 h femoral neck fracture. The primary intention of this research was to identify deterioration of fracture retention with an ensuing unplanned trip to the operating room in femoral neck fractures Garden types 1 and 2. Secondary were included unplanned readmissions and complications such as surgical site infection. Results A total of 41 undisplaced femoral neck fractures (Garden types 1 and 2) were included in this study; n = 20 were in the resulting admission operatively treated (group 1) and n = 21 were treated conservatively. The mean age in group 1 was 76 years; women (70%). In group 2 it was 81 years with a female dominance (71.4%). Admission status: Garden types 1 and 2, group 1 n = 13/7 and group 2 n = 15/6. Subsequent femoral neck fracture displacement (Y/N) (in case of operation, before operation) group 1 n = 14/6 and group 2 n = 6/15. Conclusion According with our results, patients sustaining Garden type 1 femoral neck fractures, depending on age and comorbidities, should be treated conservatively with weight bearing and under physiotherapeutic instructions. In case of femoral neck fractures Garden type 2, a surgical treatment should be performed in order to avoid femoral neck fractures to slip after weight bearing by lacking of fracture impaction.

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“…However, CT can effectively improve the identification accuracy of FNF Garden classification because CT examination is less affected by postures, and through thin-slice reconstruction, VR, MPR and other processing, CT can effectively reconstruct the 3D image of femoral neck and clearly and intuitively display the changes of bone cortex [ 22 ]. However, whether the accuracy and repeatability of classification based on CT data are really better than that based on plain radiographs is also controversial [ 23 ].…”

Section: Introductionmentioning

confidence: 99%

Does Garden type I incomplete femoral neck fracture really exist in older adults? To evaluate the stability and consistency of Garden classification

et al. 2022

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Background Accurate classification of femoral neck fracture (FNF) is crucial for treatment plan and therapeutic outcomes. Garden classification is commonly used in the clinic, but its stability and consistency remain controversial. The aim of this study was to evaluate the stability and consistency of Garden classification based on X and CT images, and to analyze whether it is valid for Garden I in the elderly. Methods X-ray and CT images from 886 elderly patients with FNF were collected, four orthopaedic surgeons and four radiologists evaluated these images independently, and determined the fracture type based on Garden classification. Three months later, The exercise was repeated and the results were compared based on 4 types Garden classification (I, II, III and IV) and 3 types Garden classification (I + II, III and IV). Kappa was used to measure inter- and intraobserver agreement. The patients with Garden I incomplete FNF confirmed by 8 observers together based on images combined with medical history were compared with the intraoperative results. Results Four types Garden classification, there was little consistency inter- and intraobservers (Kappa from 0.18 to 0.43) based on X-ray images, while professors consistency (0.56 to 0.76) was higher than residents (0.28 to 0.35) based on CT. 3 types Garden classification showed almost perfect agreement inter- and intraobservers, which ranged from 0.76 to 0.90. Totally 52 patients were diagnosed as Garden I, 38 of whom underwent arthroplasty. All surgical cases showed complete fracture during operation. Conclusions There was low consistency and repeatability in 4 types Garden classification (I, II, III and IV), while 3 types Garden classification (I + II, III and IV) had high consistency among observers. In the elderly, all undisplaced femoral neck fracture may be Garden II, no Garden I.

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Is non-operative treatment still relevant for Garden Type I fractures in elderly patients? The femoral neck impaction angle as a new CT parameter for determining the indications of non-operative treatment

Cited by 9 publications

References 16 publications

A three-dimensional measurement study of fracture displacement in Garden I femoral neck fracture: a retrospective study

A three-dimensional measurement study of fracture displacement in Garden I femoral neck fracture: a retrospective study

Challenging the dogma to “always operate” acute hip fractures: a proof-of-concept pilot study for nonoperative management of undisplaced femoral neck fractures

Does Garden type I incomplete femoral neck fracture really exist in older adults? To evaluate the stability and consistency of Garden classification

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