Preoperative posterior tilt of at least 20° increased the risk of fixation failure in Garden-I and -II femoral neck fractures

Background and purposeThe operative treatment of hip fractures in Norway has changed considerably during the last decade. We used data in the Norwegian Hip Fracture Register to investigate possible effects of these changes on reoperations and 1-year mortality.Patients and methods72,741 femoral neck (FFN) fractures and trochanteric fractures in patients 60 years or older were analyzed. The fractures were divided into 5 time periods (2005–2006, 2007–2008, 2009–2010, 2011–2012, 2013–2014). Cox regression models were used to calculate unadjusted and adjusted (age group, sex, and ASA class) relative risks (RRs) of reoperation and of 1-year mortality in the different time periods.ResultsFor undisplaced FFNs treatment with hemiarthroplasty increased from 2.1% to 9.7% during the study period. For displaced FFNs treatment with arthroplasty increased from 56% to 93%. The use of intramedullary nails increased from 9.1% to 26% for stable 2-fragment (AO/OTA A1) trochanteric fractures, from 15% to 33% for multifragment (AO/OTA A2) trochanteric fractures, and from 27% to 61% for intertrochanteric fractures (AO/OTA A3)/subtrochanteric fractures. Compared with the first time period the adjusted 1-year RR for reoperation was 0.43 (95% CI: 0.37–0.49) for displaced FFNs in the last time period. The adjusted 1-year mortality in the last time period was lower for all fractures (RR: 0.87 (0.83–0.91)), displaced FFNs (RR: 0.86 (0.80–0.93)), AO/OTA A1 trochanteric fractures (RR: 0.79 (0.71–0.88)), and AO/OTA A2 trochanteric fractures (RR: 0.87 (0.77–0.98)) when compared with the first study period.InterpretationHip fracture treatment in Norway has improved: The risk of reoperation and the 1-year mortality after displaced femoral neck fractures have decreased over a 10-year period. National registration is useful to monitor trends in treatment and outcomes after hip fractures.

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“… 2009 , Dolatowski et al. 2016 ). Traditionally, only displacement in the AP view has been considered when deciding the treatment of FFNs.…”

Section: Discussionmentioning

confidence: 99%

“… 2009 , Dolatowski et al. 2016 ). The Garden classification, which is used in the NHFR dataset, classifies these fractures as undisplaced despite displacement in the lateral view.…”

Section: Discussionmentioning

confidence: 99%

Improved outcome after hip fracture surgery in Norway

et al. 2017

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“…19,[26][27][28] On the other hand, patients with a nondisplaced FNF treated with internal fixation have shown lower satisfaction and functional results than patients with displaced FNF treated with an arthroplasty, probably Journal of Orthopaedic Surgery 27 (2) associated with their higher risk of complications. 19,26 Thus, tools that help us determine individual risk of failure, such as the posterior tilt angle in some series, are increasingly relevant, [9][10][11]29 even when some have failed to probe the same results. 30 This study has several limitations.…”

Section: Discussionmentioning

confidence: 99%

The influence of the CT scan in the evaluation and treatment of nondisplaced femoral neck fractures in the elderly

Zamora

Klaber

Ananías

et al. 2019

J Orthop Surg (Hong Kong)

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Background: The management of nondisplaced femoral neck fractures (FNFs) has evolved, with emphasis in radiographic features such as posterior displacement. However, the role of advanced imaging in this scenario is still not well defined. Therefore, our objective is to assess the impact of a computed tomography scan (CT) on interobserver agreement (IA) of fracture classification, posterior tilt measurement, and treatment decisions in nondisplaced FNF in elderly patients. Methods: Eleven patients with a nondisplaced (Garden 1-2) FNF were assessed by six hip surgeons. On a first stage, fracture classification, posterior tilt, and treatment plan (fixation/arthroplasty) were determined only with clinical information and X-rays. On a second stage, a CT was added. The kappa coefficient (k) and intraclass correlation coefficient (ICC) were used to determine IA. Results: IA for Garden classification was only slight in X-rays and with the addition of a CT, with a k ¼ 0.13 (0-0.28) and 0.18 (0.03-0.33), respectively. Conversely, posterior tilt measurement agreement was excellent in both schemes, with an ICC ¼ 0.92 (0.83-0.98) and 0.92 (0.82-0.98). The IA for the proposed treatment was slight with X-rays (k ¼ 0.44; 0.29-0.6), but moderate with the addition of a CT scan (k ¼ 0.67; 0.52-0.82). Changes in surgical decision where made in 14 of 66 evaluations with an OR ¼ 1.4 (0.62-3.2) for choosing an arthroplasty if a CT was used. Conclusion: IA for fracture classification and posterior tilt evaluation in nondisplaced FNF was not altered by the usage of a CT. There is improvement in treatment agreement when a CT scan is added to conventional imaging, with changes in treatment in 21% of cases.

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“…Some studies suggest that for Garden I and II fractures-in particular, valgus-impacted femoral neck fracturesintraoperative reduction does not in uence the success of the surgery. [5,6] It has also been argued that as valgus-impacted fractures can destabilize after reduction, there is no need for anatomic reduction. [7] Others recommend anatomic reduction because the fact that malreduction signi cantly increases the risk of long-term complications.…”

Section: Introductionmentioning

confidence: 99%

Finite Element Analysis of Necessity of Reduction and Selection of Internal Fixation for Valgus-impacted Femoral Neck Fracture

Dai¹,

Dou³

et al. 2020

Preprint

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BackgroundAlthough valgus-impacted fractures don’t displace obviously, a larger valgus angle and posterior tilt of the femoral head can cause hip joint dysfunction and femoral head necrosis. The optimal surgical approach for valgus-impacted femoral neck fractures remains controversial. This study compared the biomechanical characteristics of different treatment strategies based on finite element analysis.MethodsTen valgus-impacted femoral neck fractures were analyzed in terms of posterior tilt and valgus angle measured on X-ray radiographs. Using these data, we generated 7 finite element models that were compared in terms of von Mises stress distribution and displacement.ResultsIn the intact femur, von Mises stress was concentrated at the medial and inferior sides of the femoral neck. In valgus-impacted femoral neck fractures, von Mises stress was at the same locations but was 5.66 times higher than that in the intact femur. When 3 cannulated screws were used for internal fixation, anatomic reduction diminished the stress at the fracture end from 140.6 to 59.14 MPa, although displacement increased from 0.228 to 0.450 mm. When the fracture was fixed with a sliding hip screw (SHS) + cannulated screw, there was less stress at the fracture end and greater displacement with anatomic reduction than that without reduction (stress: 15.9 vs 37.9 MPa; displacement: 0.329 vs 0.168 mm).ConclusionsThe SHS + cannulated screw has superior biomechanical stability than 3 cannulated screws, and is recommended following anatomic reduction to treat valgus-compacted femoral neck fractures.

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Preoperative posterior tilt of at least 20° increased the risk of fixation failure in Garden-I and -II femoral neck fractures

Cited by 64 publications

References 21 publications

Improved outcome after hip fracture surgery in Norway

Improved outcome after hip fracture surgery in Norway

The influence of the CT scan in the evaluation and treatment of nondisplaced femoral neck fractures in the elderly

Finite Element Analysis of Necessity of Reduction and Selection of Internal Fixation for Valgus-impacted Femoral Neck Fracture

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