Objective To compare the effects of arthroplasty with that of intenal fixation for displaced femoral neck fractures in the elderly. Methods We searched for all randomized controlled trials and quasi-randomized controlled trials of hip arthroplasty versus internal fixation for displaced femoral neck fractures in the elderly by electronically searching MEDLINE( 1966 to September, 2006),EMbase(1966 to September, 2006), Cochrane Library( Issue 4 2006), CBM( up to September, 2006) and CNKI (September, 2006) and handsearching grey literatures. The quality of the trials was assessed and meta-analyses were conducted using The Cochrane Collaboration’s RevMan 4.2.8 software. The quality of the trials was assessed. And meta-analysis was conducted by using RevMan4.2.8 software. Results A total of 228 papers were retrieved, but only 15 published randomized controlled trials involving a total of 2 254 patients were suitable for inclusion in the review. Based on the meta-analyses, hip arthroplasty showed obvious advantages over internal fixation in terms of the incidences of major complications after 2 years (RR 0.15 ; 95%CI 0.09 to 0.23) and after 5 years (RR 0.18 ; 95%CI 0.11 to 0.30) as well as re-operation rate (RR0.12 ; 95%CI 0.08 to 0.18) after 2 years, and after 5 years (RR0.11 ; 95%CI 0.06 to 0.22), there was an advantage to performing hip asthroplasty. After one year, the mortality was the same in both groups with RR 1.05 and 95%CI 0.89 to 1.23. Conclusion There is an evidence base to support arthroplasty as a treatment for displaced femoral neck fractures in the elderly. Arthroplasty can not only decrease the rate of re-operation, but can also reduce the incidence of complications, with similar one-year mortality when compared to internal fixation.
Objective To summarize the surgical technique and the effectiveness of Becker V-shaped lateral rotation osteotomy in total hip arthroplasty (THA) for Crowe type IV development dislocation of the hip (DDH). Methods Between January 2000 and December 2009, 18 patients (22 hips) with Crowe type IV DDH underwent THA. There were 3 males and 15 females with an average age of 54 years (range, 41-75 years). The unilateral hip was involved in 14 cases and bilateral hips in 4 cases. All patients had over anteversion of the femoral neck, with the acetabular anteversion angle of (21.28 ± 4.87)°, the femoral neck anteversion angle of (59.06 ± 1.44)°, and combined anteversion angle of (80.33 ± 1.55)°. All the patients had limb-length discrepancy, ranged from 1.0 to 3.5 cm (mean, 2.5 cm). Before operation, gluteus medius muscle strength was grade 2 in 17 hips and grade 3 in 5 hips; severe or moderate claudication was observed in 13 and 5 patients, respectively. Trendelenburg sign was positive in all patients. Preoperative Harris score was 30.00 ± 6.32. Cementless prosthesis was used. Becker V-shaped lateral rotation osteotomy and subtrochanteric shortening with overlapping femoral resection were performed, and proximal femoral shaft splitting was performed on 21 hips having narrow bone marrow cavity. Results All the cases achieved primary healing of incision. No complication of anterior dislocation, deep infection, nerve traction injury, or femoral uncontrolled fracture occurred. All the cases were followed up 3-12 years (mean, 8 years). Postoperative X-ray films showed that the initial fixation result of femoral prosthesis was excellent in 18 hips and good in 4 hips. Bone healing of osteotomy stump was obtained at 3-6 months (mean, 5 months) after operation. Affected limb prolonged for 2.5-3.5 cm (mean, 3.0 cm ) at 1 year after operation; limb-length discrepancy was 0.5-1.5 cm (mean, 1.0 cm). The gluteus medius muscle strength was restored to grade 4 in 5 hips and grade 5 in 17 hips. At last follow-up, 13 patients had no claudication, and 5 patients had mild claudication; Trendelenburg sign was negative in 15 cases and was positive in 3 cases; the Harris score was significantly improved to 91.89 ± 3.22; all showing significant difference when compared with preoperative ones (P lt; 0.05). At last follow-up, the acetabular anteversion angle, the femoral neck anteversion angle, and combined anteversion angle were (19.33 ± 4.49), (13.33 ± 5.70), and (32.67 ± 5.35)°, respectively, all showing significant differences when compared with preoperative ones (P lt; 0.05). No aseptic loosening, osteolysis, or rediolucent line was found around the femoral component. No implant subsidence, stem varus, or revision occurred. Conclusion Becker V-shaped lateral rotation osteotomy is a safe and predictable method to treat type Crowe type IV DDH.
Objective To compare the curative effect of dynamic hi p screw (DHS) combined with anti-rotation screw and cannulated screw in treating patients with Pauwels type II or III femoral neck fracture and to provide the basis for the choice of surgical procedure. Methods Between March 2008 and September 2009, 51 patients with fresh Pauwels type II or III femoral neck fracture were treated with DHS combined with anti-rotation screw (DHS group) and three cannulated screws (cannulated screw group). The DHS group included 23 patients, 13 males and 10 females, aging 27-59 years (mean, 43.2 years); fracture was caused by fall ing in 1 case, by traffic accident in 17, by fall ing from height in 5 with a mean time of 27 hoursfrom injury to hospital ization (range, 12-70 hours); and 23 fractures included 9 Pauwels type II and 14 Pauwels type III femoral neck fracture. The cannulated screw group included 28 patients, 12 males and 16 females, aging 20-60 years (mean, 40.7 years); fracture was caused by fall ing in 1 case, by traffic accident in 22, by fall ing from height in 5 with a mean time of 25 hours from injury to hospital ization (range, 9-38 hours); and 28 fractures included 12 Pauwels type II and 16 Pauwels type III femoral neck fracture. There was no significant difference in the basel ine characteristics between 2 groups (P gt; 0.05). Results The incision heal ing of both groups by first intention was achieved. There were significant differences in operation time, incision size, operation blood loss, the cases of blood transfusion, the amount of blood transfusion, C reaction protein level on the 2nd postoperative day, and hospital ization days between 2 groups (P lt; 0.05). In DHS group, anatomic reduction was observed in 20 cases (86.96%) and satisfactory reduction in 3 cases (13.04%), while in cannulated screw group, anatomic reduction was observed in 25 cases (89.29%) and satisfactory reduction in 3 cases (10.71%) ; there was no significant difference (χ2=0.660, P=1.000). The patients were followed up 12-30 months with an average of 14.8 months. There was no significant difference (P gt; 0.05) in the rate of nonunion (10.71% vs. 0), the implant failure (3.57% vs. 0), and avascular necrosis of the femoral head (10.71% vs. 0) between the DHS group and the cannulated screw group. The union time was (94.5 ± 2.0) days in the DHS group and (106.0 ± 33.5) days in the cannulated screw group, showing no significant difference (t=—1.641, P=0.107). The re-opereation rates and the overall success rates were 25% and 75% in the cannulated group and were 0 and 100% in the DHS group, showing significant differences (χ2=6.650, P=0.012). At last follow-up, there was no significant difference in Harris hip score and visualanalogue scale (VAS) score between DHS group and cannulated screw group (P gt; 0.05). Conclusion The optimal treatment of young adults Pauwels type II or III femoral neck fracture is DHS combined with anti-rotation screw with an high overall success and less compl ications.
Objective To explore the effectiveness of pedicled il iac bone graft transposition for treatment of avascular necrosis of femoral head (ANFH) after femoral neck fracture. Methods Between June 2002 and December 2006, 22 cases (22 hips, 16 left hips and 6 right hips) of ANFH after femoral neck fracture were treated with il iac bone graft pedicled with ascending branch of the lateral femoral circumflex vessels. There were 18 males and 4 females with an age range from 28 to 48 years (mean, 37.5 years). The time from injury to internal fixation was 2-31 days, and all fractures healed within 12 months after internal fixation. The ANFH was diagnosed at 15-40 months (mean, 22 months) after internal fixation. The ANFH duration was 3-11 months (mean, 8 months). According to Association Research Circulation Osseous (ARCO) staging system, 2 hips were classified as stage IIa, 3 hips as stage IIb, 3 hips as stage IIc, 3 hips as stage IIIa, 7 hips as stage IIIb, and 4 hips as stage IIIc. The preoperative Harris hip score (HHS) was 64.10 ± 5.95. Results All incisions healed by first intention and the patients had no compl ication of lung embol ism, sciatic nerve injury, lower l imb deep venous thrombosis, and numbness and pain of donor site. All patients were followed up 2.5 to 6.3 years (mean, 4.8 years). The fracture heal ing time was 8-12 months, and no femoral neck fracture recurred. The HHS was 90.20 ± 5.35 at last follow-up, showing significant difference when compared with the preoperative value (t= —18.447, P=0.000). The hi p function were excellent in 11 hi ps, good in 10 hips, fair in 1 hip, and the excellent and good rate was 95.5%. Four hips were radiographically progressed in ARCO staging, 18 hips remained stable with a stable rate of 81.8%. Conclusion Pedicled il iac bone graft transposition is an ideal option for treatment of ANFH after internal fixation of femoral neck fracture for the advantages of femoral head revascularization, sufficient cancellous bone supply, and relatively simple procedure.
Objective To compare the efficiency of secondary total hip arthroplasty (THA) for osteonecrosis of the femoral head (ONFH) after failed internal fixation of femoral neck fracture and the primary THA for non-traumatic ONFH and to evaluate if the two groups have significant difference. Methods From June 2004 to July 2007, 203 cases of ONFH were treated by THA. In group A, 83 patients (83 hips) with ONFH after failed internal fixation included 56 males (56 hips) and 27 females (27 hips) with an average age of 58.3 years (range 45-75 years). According to Ficat classification, there were 61 cases atstage III and 22 cases at stage IV. The Harris score was 37.6 ± 2.0. The disease course was 1-6 years with an average of 2.6 years. In group B, 120 patients (167 hips) with non-traumatic ONFH included 67 males (94 hips) and 53 females (73 hips) with an average age of 52.6 years (range 41-67 years). According to Ficat classification, there were 56 cases (83 hips) at stage III and 64 cases (84 hips) at stage IV. The Harris score was 38.2±1.0. The disease course was 1.5-5.0 years with an average of 2.6 years. There were no significant differences in general data between two groups (P gt; 0.05). Results All 203 cases were followed up for 2 to 5 years (average 3.4 years). There were no significant differences in the operation time of single-hip, the blood loss, the blood transfusion between two groups (P gt; 0.05). Intraoperative fractures occurred in 4 hips (4.8%) of group A and 2 hips (1.2%) of group B, showing significant difference (P lt; 0.05). There were no significant differences (P gt; 0.05) in the incidence of dislocation [3 hips (3.6%) in group A and 1 hip (0.6%) in group B], continuous femoral pain [2 hips (2.4%) in group A and 1 hip (0.6%) in group B] and infection [1 hip (0.6%) in group B] between two groups. There were no significant differences (P gt; 0.05) in acetabular abduction, anteversion, femoral anteversion, and combined anteversion angles as well as the recovery rate of acetabular rotational center between two groups. The Harris scores of groups A and B after 2 years were 79.4 ± 2.1 and 84.2 ± 3.5.There was no significant difference between two groups (P gt; 0.05). The Harris score postoperation had significant differences compared with preoperation (P lt; 0.05). Conclusion Compared to the primary THA to non-traumatic ONFH, secondary THA to ONFH after failed internal fixation has no significant increase in operative difficulty, the postoperative hip function isgood, but the incidence of intraoperative fracture is higher.
Objective To investigate the specific variables and influence factors of Harris scores in follow-up data of patients with internal fixation of femoral neck fracture. Methods From May 1999 to May 2004, 99 cases of femoral neck fracture receiving close reduction with cannulated screw and having complete follow-up data were evaluated in terms of age, sex, type of bone fracture (Garden classification), reduction time, reduction qual ity (Garden indicators), time of full weight-loading, removal of internal fixation, traction before operation, side of bone fracture, necrosis of femoral head, duration of follow-up and Harris score during follow-up period. Univariate and multivariate were analyzed by SPSS14.0 and SAS8.2. Results P-P probabil ity plot and normal test revealed the Harris scores were non-normal distribution (W=0.757 09, P=0.000 1). By nonparametric test in univatiate analysis, the following variables in Harris scores were of statistic significance: the time of reduction (U=— 2.289, P=0.022), the Garden classifaction (H=16.943, P=0.001), the time of full weight-bearing (U=— 3.069, P=0.002), the qual ity of reduction (U=— 3.448, P=0.001) and the necrosis of femoral head (U=— 4.723, P=0.000).By the analysis of correlation, the following variables in Harris scores were of statistic significance: Garden classification(rs=— 0.412, P=0.000), the time of reduction (rs=— 0.231, P=0.021), the qual ity of reduction (rs=— 0.348, P=0.000), the time of full weight-bearing (rs=— 0.310, P=0.002), and the necrosis of femoral head (rs=— 0.477, P=0.000). By the univariate logistic regression analysis, the following variables in Harris scores were of statistic significance: Garden classification (P=0.000 1), the time of reduction (P=0.012 6), the qual ity of reduction (P=0.000 3), the time of full weight-bearing (P=0.003 2), the traction before operation (P=0.049 2) and the necrosis of femoral head (P=0.000 1). By the multivariate logistic regression analysis, the influence factors of Harris scores rank included the necrosis of femoral head (P=0.000 1), the time of reduction (P=0.028 2), and Garden classification (P=0.000 7). Conclusion Harris scores is of non-normal distribution, and the necrosis of femoral head is the most important factor influencing the function after applying internal fixation with cannulated screws to femoral neck fracture.
Objective To explore the biomechanical stabil ity of ideal compression screw (I.CO.S.) for treatment of femoral neck fracture and to provide theoretical basis for choosing I.CO.S. in cl inical appl ication. Methods Thirty cadaveric human femurs were selected and divided randomly into experimental group (n=15) and control group (n=15), 15 in each group were divided equally into three sub-groups (n=5) again. The model of subcapital femoral neck fracture was made, then given anatomical reduction and fixed with I.CO.S. (experimental group) and general cannulated compression screw (control group) separately with three different configurations: two horizontal (parallel screws in superior aspect of femoral neck), two vertical (parallel screws in sagittal plane of femoral neck) and reverse triangle. The different biomechanical performances were evaluated through experimental stress analysis. Results In biomechanical stabil ity aspect: groups A, B, C was better than groups D, E, F in respect of horizontal displacement and yield load (P lt; 0.05); groups A, D was better than groups B, E in respect of the straining, horizontal displacement and yield load (P lt; 0.05); and there were not significant differences in all biomechanical indicators between group C and group F, and between group A and group C(P gt; 0.05). Conclusion I.CO.S. has the good biomechanical stabil ity for treatment of femoral neck fracture, which mayprovide basis for appl ication.
Objective To investigate whether the biomechanical effect of mushroom shaped surface prosthesis on femoral neck is in the scope of safety after the replacement. Methods Four donated fresh-adult specimens of upper femur under the age of 55 years old were used. The strains of detecting points A (lateral) and B (medial) on the narrow place of femoral neck in the standing position were simulated for three stages before or after the prosthesis replacement, namely the pre-replacement, the initial stage during which the interspace of the prosthesis was filled with cancellous bone, and laterstage during which the interspace of the prosthesis was filled with bone cement. Then they were compared by using l inear regression analysis in Excel and rel iabil ity analysis. Results The regression analysis showed that the values of correlation coefficient r were all more than 99% at the different stages, indicating the strain of femoral neck’s cortical bone was proportional to the load and there was no occurrence of the plastic deformation of the femoral neck. For point A, the slope of the trend l ine of strain was 0.671 9 at the pre-replacement stage. The value of the initial stage after replacement was 0.619 2 and its change rate was —7.8%; while corresponding value was 0.662 7 and —1.4% at the later stage after replacement. For point B, the slope of the trend l ine of strain was —1.056 1 at the pre-replacement stage. The value of the initial stage after replacement was — 1.129 2 and its change rate was 6.9%; while corresponding value was —1.085 1 and 2.7% at the later stage after replacement. Conclusion The mechanical strength of femoral neck is in the scope of safety after surface replacement of the femoral head. The change rate of strain at the later stage is smaller than the initial stage.
Objective To explore an ideal operative treatment to preserve the hi p joint for the old femoral neck fracture in young and middle-aged patients. Methods Between January 2002 and June 2006, 28 cases of old femoral neck fracture, 23 males and 5 females, aged 19-55 years old (37.6 on average), were reconstructed with free il iac grafts and fixed by dynamic hi p screws (DHS) and/or canulated screws. Multi ple vascular bundles derived from lateral circumflex femoral vascular were implanted in 19 cases. All the 28 cases were close fractures, with 17 of left hip and 11 of right hip. In terms of the fracture site, 4 cases were infer-head, 17 were per-neck and 7 were fundamental-form. The Harris score was 25-72 (49.6 onaverage) before operation. No callus formation was found on X-ray films in all cases; sclerosis and cyst were found in 4 cases and osteonecrosis of femoral head (ONFH) was confirmed by MRI. The duration between initial injury and surgery was 1-21 months (8.6 months on average). Results No deep infection was observed in all 28 cases, and paralysis of the lateral cutaneous nerve of the thigh was observed in 5 cases, and was better 6 months after operation with no special treatment. All 28 cases were followed up for 20-72 months (35.8 months on average). A total of 25 fractures healed within 4-8 months, with the heal ing rate of 89.3%; 3 fractures had nonunion and received artificial hip replacement. During the follow-up, 7 cases (25%) developed ONFH confirmed by MRI within 18 months, and 5 cases (17.9%) developed femoral head collapse. The Harris score was 27-100 (82.7 on average). Leg length discrepancy was not observed and the gait was fairly normal. Conclusion The femoral neck reconstruction procedure can restore the normal anatomy of femoral head and neck and the blood supply, so as to promote fracture heal ing as well as delay or avoid the artificial joint replacement. Therefore, it is an important treatment to preserve the hip joint for the old femoral neck fracture in young and middle-aged patients.
Objective To evaluate the clinical effect of cannulatedscrew on treatment of femoral neck fracture(FNF). Methods Forty-two FNFpatients were treated by using cannulated screw from January 2001 to December 2005.There were 22males and 20 females with an average age of 41 years (19-59 years). Fracture was caused by traffic accident in 21 cases, by falling from height in 14 cases and by bruise in 7 cases. All cases were fresh fracture. According to Garden criterion for typing, 15 cases were classified as type Ⅱ, 16 cases as type Ⅲ and 11 cases as type Ⅳ . It was 7 hours to 15 days from injury to operation. Results Thepatients were followed up for 1-6 years with an average of 2.5 years. The average fracture union time was 6.5 months. Three patients had ischemic necrosis of femoral head, andloosening and breakage of screw and rob was observed in 1 case. According to Brumback criterion for hip joint function, the result was excellent in 18 cases, good in 20 cases and bad in 4 cases, and the excellent and good rate was 90.4%. Conclusion Cannulated screw fixation is a good method to treat FNF in young adults. It can improve the rate of fracture union and reduce the rate of avascular necrosis of femoral head.