Not All Garden-I and II Femoral Neck Fractures in the Elderly Should Be Fixed

Abstract

Background: Internal fixation is currently the standard of care for Garden-I and II femoral neck fractures in elderly patients. However, there may be a degree of posterior tilt (measured on preoperative lateral radiograph) above which failure is likely, and primary arthroplasty would be preferred. The purpose of this analysis was to determine the association between posterior tilt and the risk of subsequent arthroplasty following internal fixation of Garden-I and II femoral neck fractures in elderly patients. Methods: This study is a preplanned secondary analysis of data collected in the FAITH (Fixation using Alternative Implants for the Treatment of Hip fractures) trial, an international, multicenter, randomized controlled trial comparing the sliding hip screw with cannulated screws in the treatment of femoral neck fractures in patients ≥50 years old. For each patient who sustained a Garden-I or II femoral neck fracture and had an adequate preoperative lateral radiograph, the amount of posterior tilt was categorized as <20° or ≥20°. Multivariable Cox proportional hazards analysis was used to assess the association between posterior tilt and subsequent arthroplasty during the 2-year follow-up period, controlling for potential confounders. Results: Of the 555 patients in the study sample, 67 (12.1%) had posterior tilt ≥20° and 488 (87.9%) had posterior tilt <20°. Overall, 73 (13.2%) of 555 patients underwent subsequent arthroplasty in the 24-month follow-up period. In the multivariable analysis, patients with posterior tilt ≥20° had a significantly higher risk of subsequent arthroplasty compared with those with posterior tilt <20° (22.4% [15 of 67] compared with 11.9% [58 of 488]; hazard ratio, 2.22; 95% confidence interval, 1.24 to 4.00; p = 0.008). The other factor associated with subsequent arthroplasty was age ≥80 years (p = 0.03). Conclusions: In this analysis of patients with Garden-I and II femoral neck fractures, posterior tilt ≥20° was associated with a significantly increased risk of subsequent arthroplasty. Primary arthroplasty may be considered for Garden-I and II femoral neck fractures with posterior tilt ≥20°, especially among older patients. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Preoperative Posterior Tilt Increases the Risk of Later Conversion to Arthroplasty After Osteosynthesis for Femoral Neck Fracture

“…The total reoperation rate in our study population was 25%, and 16% of the patients underwent conversion to arthroplasty. These findings are similar to those of previous studies, which have reported reoperation rates between 16% and 33% (Palm et al 2009, Lapidus et al 2013, Bartels et al 2018, Nyholm et al 2018, Okike et al 2019, Stockton et al 2019. Reoperation rates have been found to vary in the literature depending on which operations were defined as J o u r n a l P r e -p r o o f relevant reoperations (Nyholm et al 2018, Stockton et al 2019).…”

“…Further, there was no difference in risk of conversion to arthroplasty between patients with non-displaced FNF with a <0° or ≥20° posterior tilt and patients with displaced FNF, suggesting that the effect of posterior tilt on later failure of internal fixation is as important as displacement on the AP radiograph. Comparably to our results, Okike et al reported an increased risk of later conversion to arthroplasty in patients with a posterior tilt of ≥20° (Okike et al 2019). Stockton et al reported a conversion-to-arthroplasty rate of 14% in patients aged 18-50 years (Stockton et al 2019).…”

“…The definition of posterior tilt was first introduced by Palm et al in 2009 and later further validated (Palm et al 2009, Kalsbeek et al 2020. Posterior tilt of the femoral head of >20° on lateral view has been shown to be an individual predictor of failure in non-displaced FNFs (Palm et al 2009, Okike et al 2019, Nielsen et al 2020, although this has not been observed in all studies (Lapidus et al 2013). Lately, also the quality of reduction on lateral view has been studied and a correlation found between postoperative posterior tilt of the femoral head and reoperation (Nyholm et al 2018(Nyholm et al , 2019.…”

Long‐Term Efficacy of Screw Fixation vs Hemiarthroplasty for Undisplaced Femoral Neck Fracture in Patients over 65 Years of Age: A Systematic Review and Meta‐Analysis

“…Osteonecrosis of femoral head and nonunion were the primary causes for reoperation after internal fixation. Furthermore, high preoperative anterior tilt or posterior tilt, low bone mineral density, patient age, gender, and higher body mass could increase the risk of reoperation in Garden I and II femoral neck fractures treated with cannulated screws 21–25 . Screw fixation could not provide a satisfactory long‐term reoperation rate in elderly patients with undisplaced femoral neck fractures.…”

Anterior Positioning Screw in Proximal Femoral Plating Restricts Posterior Tilt of Retroverted Femoral Neck Fractures: a Retrospective Cohort Study

“…In internal xation of femoral neck fractures, xation failure is not uncommon, and no consensus has been reached regarding the optimal xation construct. Preoperative posterior tilt (or retroversion) of the femoral head has been recognized as an important risk factor for xation failure of femoral neck fractures [3][4][5]. Since retroversion of the femoral head would largely cause damage of the posterior cortex and/or weaken the osseous mechanical transduction, the fracture would still present with posterior instability even after anatomic reduction.…”