Treatment results of displaced femoral neck fractures

505 Treatment results of displaced femoral neck fractures Clinic of Orthopedics and Traumatology, Kaunas University of Medicine, Lithuania Key words: femoral neck fractures, osteosynthesis, hemiarthroplasty, total hip replacement. Summary. Retrospective study of 372 patients with Garden III IV type intracapsular femoral neck fractures performed in Clinic of Orthopedics and Traumatology, Kaunas University of Medicine, Kaunas Red Cross hospital. Ninety eight percent of them were operated: osteosynthesis for 302 patients, and arthroplasty for 63 patients. Evaluating results of treatment we paid attention on walking ability, pain in hip joint. Mean follow-up time was 1.5 years. Satisfactory results we received for 41.8%. The best results we received after total hip replacement and after osteosynthesis with modern fixation devices. Delayed surgery worsens results. Type of anesthesia did not influence results of osteosynthesis. Introduction The increasing number of patients with hip fractures is a matter of great relevance to our society (1, 13). The increasing expenses of treatment, a big number of unsatisfied results force us to search for optimal treatment methods. Speed s phrase unsolved fracture was postulated 50 years ago postulated, however this problem remains despite the improvement of fixation methods and the improvement of hip replacement techniques (2). The frequency of femoral neck fracture is related to development of osteoporosis in older people (3, 10), especially during post-menopause period. Nonunion and aseptic necrosis of femoral neck after femoral neck osteosynthesis is common: 10-30% and 15-30% respectively (1, 3). The main purpose of the treatment is to restore patient s functional status to preinjury state (1). The requirements for up-to-date fixators were formulated under the development of biomechanics (13). While using these fixators, physiological compression of fragments is allowed; the rotation instability is eliminated this way allowing early weight bearing i. e. dynamization. Time factor plays an important role to results of osteosynthesis. Blood supply to the femoral head is disordered in displaced femoral neck fractures, and it is supposed, that early operations (up to 6 hours after the trauma) help to decrease incidence of aseptic femoral neck necrosis (5, 11, 13). Another important factor that influences blood supply is an intraarticular pressure, which increases after the formation of intraarticular hematoma. The aspiration of the hematoma and the decrease of intraarticular pressure influences healing of non-displaced femoral neck fractures (5). Increased pressure wasn t noticed in displaced fractures. The replacement of hip joint enables to avoid many undesirable complications but it is not acceptable to young people and it is also more expensive and is accompanied by higher death rate comparing with osteosynthesis (2). The results after femoral neck fractures treated by THR are 3-4 times worse than THR after osteoarthrosis (6). The aim of work: To estimate the effect of different operational treatment methods of femoral neck fractures, dependence of treatment results on the time of performed operation and type of anesthesia type. Materials and methods Femoral neck fractures have been treated by making closed reduction of fragments, under the fluoroscopic control with C arm and fixing the fragments by various fixators. These fixators were divided into 2 groups, according to up-to-date requirements formulated by Hansson. Fixators, satisfying up-to-date requirements should have fixation of proximal fragment, neutralize rotation motion between fragments, and allow physiological compression. Fixators, lacking one of these features, are singled out into a separate group. Other femoral neck fractures have been treated by hemiarthroplasty with Moor and Thompson prosthesis or having carried out THP with cemented type prosthesis. All prosthetic replacements were made through posterior approach. Correspondence to V.Jermolajevas, Clinic of Orthopedics and Traumatology, Kaunas University of Medicine, Laisvės al.17, 3000 Kaunas, Lithuania. E-mail: jermola@takas.lt

506 Treatment results were evaluated after carrying out clinical investigation of the patients, using the questionnaire for testing of the patients. The results were divided into 2 groups: and satisfactory. Good results were attributed to the cases when a patient walks without additional support and doesn t feel an ache at hip joint while walking. The analysis of retrospective study of patients treated from 1997 to 1999 in Kaunas University of Medicine, Orthopedics and Traumatology Clinic, Red Cross hospital with Garden III IV type femoral neck fractures was carried out. Medical notes were investigated and patients after femoral neck fractures were interviewed and objectively examined. Evaluating results of the treatment questionnaires were used to evaluate the functional condition of the patient, ability to bear weight and pain syndrome. Results Three hundred and seventy two patients were treated; 365 patients were operated (98.4%). The primary osteosynthesis was done to 302 patients (81.2%) and hip replacement for 63 patients (16.48%). Methods of operations are shown in Table 1. Relations between used fixators are presented in Table 2: some of them correspond to the up-to-date requirements and some of them do not. Osteosynthesis by Smith Peterson, Rydell, DHS, CITO, AO angulated plates - fixators without one of the required feature were decreasing in number comparing year 1997 and 1999 (see Table 2). Two hundred and thirty two patients out of 372 (62.6%) patients were interviewed and clinically examined. The results were evaluated according to the ability to walk, to lean on the leg, syndrome of the pain and contiguous pathology. The results of various surgeries are presented in the Table 5. Mean follow up time was 1.5 years. One hundred and seventy eight (74.7%) of 232 patients are still alive after the surgery; 54 (23.3%) patients died. The biggest part of dead patients was 80 years and more old at the time of the surgery. Most of them died within 1 to 3 months after the surgery (see Table 6). The results of osteosynthesis of femoral neck were evaluated in two groups: in the 1 st group the osteosynthesis was done using up-to-date fixators and in the Table 1. Treatment methods, 1997-1999 Treatment methods 1997 1998 1999 Total 3 6.5 mm screws 3 24 21 48 Smith-Petersen nails plus 6.5 mm srew 25 38 8 71 Smith-Petersen 41 9 1 51 Hansson 23 8 0 31 DHS 5 2 0 7 Rydell 1 22 6 29 Total arthroplasty 4 7 11 22 CITO 5 0 0 5 Angulated plate 4 2 0 6 Ullevall 2 1 51 54 Hemiarthroplasty 15 16 10 41 Not operated: skeletal traction 3 4 0 7 Total 131 133 108 372 Table 2. Use of up-to-date and outdated fixators, 1997-1999 Methods 1997 1998 1999 Total Up-to-date fixators Ullevall, Hansson, 3 6.5 mm sr. 53 71 80 204 Outdated Rydell, Smith-Petersen, CITO, 56 35 7 98 fixators angulated plates, DHS

Treatment results of displaced femoral neck fractures 507 Table 3. Ratio of and results Kind of osteosynthesis ResultsTotal With derotation and 52 38 90 proximal lock None of the above 29 75 104 mentioned features Total 81 113 194 Pearson χ 2 : 17.7279, df = 1, p = 0.000026. Table 4. Revision procedures Operative methods Cases 3 6.5 mm screws 5 Smith-Petersen nails plus 6.5 mm screw 10 Smith-Petersen 7 Hansson 1 DHS 1 Rydell 4 Total arthroplasty 1 Ullevall 4 Total 33 2 nd group the used fixators did not have at least one from the above mentioned features. The results acquired (see Table 3) draw a conclusion that the results were better using fixators that met up-to-date requirements (p<0.05). Both groups were homogeneous: they were compared according to age, sex, time from trauma to surgery and the type of anesthesia. The results of the treatment were also evaluated according to the number of revision procedures (see Table 4). Most of revisions were done after osteosynthesis when old fixators were used. The early reposition and fixation of fragments decreases the number of complications because the rest of the circulation of blood of femoral head is restored. In our study 47.6 % of all examined patients were operated during 6 hours. This could explain the big number of results: 58.23% (see Table 3). Comparing results between two groups after osteosynthesis and hemiarthroplasty (see Table 12) better results were obtained in osteosynthesis group. If the hemiarthroplasty was done, the complications associated with femoral neck necrosis and nonunion were avoided; nevertheless the results were better when osteosynthesis was done (p<0.05). Performing a hemiarthroplasty, the joint is formed by acetabulum cartilage and head of metal implant. Motion in Table 5. Results using different treatment methods Operative methods Good results Bad results Total 3 6.5 mm screws 13 14 27 Smith-Petersen nails plus 6.5 mm screw 5 29 34 Smith-Petersen 7 21 28 Hemiarthroplasty 4 15 19 Hansson 20 3 23 DHS 4 8 12 Rydell 12 15 27 Total arthroplasty 9 5 14 Ullevall 15 18 33 Non operated: skeletal traction 3 1 4 Total 92 129 221 Table 6. Age of patients who died and time period after operation Age 3 months 3-12 months After 1 year Total Younger than 60 years 0 1 0 1 60 79 years 4 4 5 13 Older than 80 years 25 10 5 40 Total 29 15 10 54

508 Table 7. Comparison of hemiarthroplasty and osteosynthesis Results Total Osteosynthesis 82 113 195 Hemiarthroplasty 3 16 19 Total 85 129 214 Pearson χ 2 : 4.98704, df = 1, p = 0.02554. Table 8. Comparison of hemiarthroplasty and total arthroplasty Table 9. Influence of anesthesia on outcomes Method of Results Total anesthesia Spinal 34 32 66 Local-intraartricular 42 38 80 Pearson χ 2 : 0.01405, df = 1, p = 0.90563. Results Total Hemiarthroplasty 3 16 19 Total arthroplasty 9 5 14 Total 12 21 33 Pearson χ 2 : 8.1924, df = 1, p = 0.00421. this joint produces erosion of the acetabulum and it causes pain and may lead to acetabulum protrusion. After total arthroplasty the joint is formed between high molecular weight polythene and metal: polythene is eroded but not the bone and pain is more rare (see Table 10). Results show that the THP is more reliable and better method than hemiarthroplasty (p<0.05). After femoral neck fractures the intraarticular hematoma is formed (5), which worsens the circulation of blood of femoral head. It is not recommended to use local anesthesia as the intraarticular pressure is increased. Increased intraarticular pressure is found only after not displaced fractures (Garden types I, II) (12). In this study only dislocated (Garden III, IV types) femoral neck fractures are examined, that is why the type of anesthesia did not influence the results of treatment (see Table 9). Discussion The most arguable problem in the field of traumatology and orthopedics is the selection of treatment methods of femoral neck fractures. Various issues give different treatment methods and results. Arthroplasty is widely spread in Central Europe; femoral neck is mostly synthesized in Scandinavia countries. Osteosynthesis is often complicated with loss of fixation, aseptic necrosis of femoral head and nonunion. Hemiarthroplasty protects from these complications but it is often accompanied by loosening of femoral component, erosion of acetabulum and protrusion. The results are better after total arthroplasty but it is an expensive method and causes more deaths after the surgery (2). In this study we investigated the influence of anesthesia, time from injury and surgery, and type of surgery to the final results. Results of treatment may depend on other factors that we might not know. Some authors claim that the results of osteosynthesis might depend on social environment (7), physical state of the patient (7), quality of achieved reposition (3), the patient s age, the state of kidneys, endocrine diseases (13) and weight. Other authors neglect the influence of these factors (9, 13). The early, precise and stable reposition enables to mobilize the patient as soon as possible, in that way the incidence of bedsores, thromboembolism, pneumonia and death after surgery is lowered (8). Other factors might influence outcomes after displaced femoral neck fractures but their meaning is not fully clear. In order to set the factors, multicentric, prospective and randomized study should be carried out. Conclusions 1. Femoral neck osteosynthesis during which, fixators that do not meet up-to-date requirements are used, causes treatment results. 2. Hemiarthroplasty is not appropriate to mobile patients because of a large number of complications after surgery. 3. Types of anesthesia do not influence results of osteosynthesis after dislocated femoral neck fractures. 4. The best results are achieved by using THR or up-to-date fixators for osteosynthesis.

Treatment results of displaced femoral neck fractures 509 Šlaunikaulio kaklo lūžių gydymo rezultatai Kauno medicinos universiteto Ortopedijos ir traumatologijos klinika Raktažodžiai: šlaunikaulio kaklo lūžiai, osteosintezė, hemiartroplastika, viso klubo sąnario protezavimas. Santrauka. Duomenys gauti atlikus retrospektyviąją 372 pacientų, gydytų Kauno medicinos universiteto Ortopedijos ir traumatologijos klinikoje, Raudonojo Kryžiaus klinikinėje ligoninėje 1997 1999 metais, analizę. Gydymo rezultatai vertinti atlikus klinikinį pacientų tyrimą bei anketinę pacientų apklausą. 372 pacientai gydyti po dislokuotų šlaunikaulio kaklo Garden III IV tipų lūžių. Operuota 98,38 proc. pacientų. Osteosintezė atlikta 302, klubo sąnario endoprotezavimas 63 pacientams. Įvertinti 232 pacientų (62,6 proc.) gydymo rezultatai. Gerų gydymo rezultatų pasiekta 41,8 proc., blogų 58,2 proc. Geresni gydymo rezultatai buvo atlikus osteosintezę šiuolaikiniais fiksatoriais arba protezavus visą klubo sąnarį. Ilgėjant ikioperaciniam gydymo laikui, gydymo rezultatai blogėja. Anestezijos metodas neįtakojo operacijos rezultatų. Adresas susirašinėjimui: V.Jermolajevas, KMU Ortopedijos ir traumatologijos klinika, Laisvės al. 17, 3000 Kaunas. El. paštas: jermola@takas.lt References 1. Koval KJ, Zuckerman JD. Hip fractures: Overview and evaluation and treatment of femoral-neck fractures. JAAOS 1994;2:141-8. 2. Davison JNS, Calder SJ, Anderson GH, et al. Treatment for displaced intracapsular fracture of the proximal femur: a prospective, randomized trial in patients aged 65 to 79 years. JBJS 2001;83B:206-12. 3. Canale ST. Campbell s Operative Orthopaedics. 9ed. Mosby; 1999. 4. Speed K. Fractures: 50 year review of teaching and treatment. Illinois Med Jr 1952;102:85-92. 5. Muller ME, Allgower M, Schneider R, Willenegger H. Manual of internal fixation. 3ed. Springer-Verlag; 1991. 6. Bray TJ, Smith-Koofer E, et al. The displaced femoral neck fracture. Internal fixation versus bipolar endoprosthesis. Results of prospective randomised comparison. Clin Orthop 1988;230:127-40. 7. Davis FM, Woolner DF, Frampton C, et al. Prospective, multicentre trial of mortality following general or spinal anaesthesia for hip fracture surgery in the elderly Br J Anaesth 1987;59(9):1080-8. 8. Zuckerman JD, Skovron ML, Koval KJ, Aharonoff G, Frankel VH. Postoperative complications and mortality associated with operative delay in older patients who have a fracture of the hip. JBJS 1995;77A:1551-6. 9. Kenzora JE, McCarthy RE, Lowell JD, Sledge CB. Hip fracture mortality: relation to age, treatment, preoperative illness, time of surgery, and complications. Clin Orthop & Rel Res 1984;Jun:45-56. 10. Aitken JM. Relevance of osteoporosis in women with fracture of the femoral neck Br Med J 1988;288:597. 11. Harper WM, Barnes MR, Gregg PJ. Femoral head blood blow in femoral neck fractures: an analysis using intraosseous pressure measurement. JBJS 1991;73 B:73. 12. Holmberg S, Dalen N. Intracapsular pressure and caput circulation in nondisplaced femoral neck fractures. Clin Orthop 1987;219:124-6. 13. Parker MJ. The cervical hip fractures. Europ instr course lect. 2001;5:67-77. Received 5 December 2001, accepted 4 April 2002