Catastrophic Failure After Open Reduction Internal Fixation of Femoral Neck Fractures With a Novel Locking Plate Implant

*Orthopaedic Trauma Service, Hospital for Special Surgery, New York, NY †Orthopaedic Trauma Service, Department of Orthopaedic Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY.
Journal of orthopaedic trauma (Impact Factor: 1.8). 03/2012; 26(10):e170-6. DOI: 10.1097/BOT.0b013e31823b4cd1
Source: PubMed


: To determine if the use of a novel proximal femoral locking plate could reduce the incidence of femoral neck shortening and improve clinical outcomes after open reduction internal fixation (ORIF) for femoral neck fractures as compared with historical controls.
: Single surgeon, retrospective case-control study.
: Academic level I trauma center.
: Twenty-one femoral neck fractures treated with the posterolateral femoral locking plate (Synthes, Inc, Paoli, PA) were eligible for inclusion. Eighteen met inclusion/exclusion criteria with a mean follow-up of 16 months.
: ORIF of femoral neck fracture with the posterolateral femoral locking plate. This consists of a side plate with multiple locking screws directed into the femoral head at converging/diverging angles and a single shaft screw. Intraoperative compression was achieved with partially threaded screws before locking screw insertion.
: Maintenance of reduction was assessed by comparing immediate postoperative and final follow-up radiographs. Clinical outcome was assessed with Harris Hip Scores after 1 year. Complications and secondary operations were noted.
: Seven (36.8%) of 18 patients experienced catastrophic failure. Five of these patients required total hip replacement, whereas the remaining 2 died before further treatment. The remaining 11 patients (61.1%) achieved bony union; the average displacement of the center of the head did not differ when compared with historical controls (0.78 mm inferiorly, 1.62 mm medially, and 2.4 degrees of increased varus vs. 0.86 mm, 1.23 mm, and 0.6 degree). Complications in this group include 1 instance of screw fracture, 2 total hip replacements, and a peri-implant subtrochanteric femur fracture. The average patient age and proportion of displaced fractures did not differ between the historical control and experimental groups. Fracture displacement was strongly associated with catastrophic failure in the experimental group only. Average Harris Hip Scores was significantly worse compared with that of historical controls (67.9 vs. 84.7, P = 0.05).
: ORIF of femoral neck fractures using a locking plate construct yielded unacceptably poor outcomes in this patient population. We hypothesize that the stiffness of this construct prevents any fracture site micromotion, placing the mechanical burden on the implant, which can result in failure at the bone-screw interface or fatigue failure of the implant itself.
: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

47 Reads
  • Source
    • "Theoretically this would improve stability of femoral neck fractures in porous bone. Unfortunately, in the heavily loaded hip, increased rigidity resulting from locked fixation seems to increase the risk of mechanical failure of both bone and implants (Glassner and Tejwani 2011, Berkes et al. 2012, Hunt et al. 2012). More research is necessary to evaluate the use of locking plate technology in the proximal femur. "
    Acta orthopaedica. Supplementum 06/2015; 86(s361). DOI:10.3109/17453674.2015.1056702
  • Source
    • ". Although locked plating constructs have been proposed as a potential solution to prevent femoral neck fracture shortening [10], clinical results of locked plate fixation for femoral neck fractures have been suboptimal [13] [14]. A recent report documented successful treatment of femoral neck fractures with a locked plating construct; however, this construct still allowed for femoral neck fracture shortening through use of telescoping fixation screws [15]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Femoral neck fractures in young adults are difficult to treat. There are substantial gaps in our knowledge regarding treatment and prevention of young adult femoral neck fractures. Avoiding malunion or nonunion of these fractures after fixation remains a challenge. Currently available fixation techniques may allow for healing to occur, but in a shortened position, with negative consequences on gait mechanics and physical function. Osteonecrosis remains a problem, affecting up to half of patients who sustain femoral neck fractures. Achieving reliable healing may require a reconsideration of fracture fixation implants as well as biological methods to address metabolic, endocrine, and/or genetic abnormalities that may be present in the young adult femoral neck fracture patient. Also, prevention of low-energy femoral neck fractures (e.g. stress fracture) remains an area ripe for investigation. Copyright © 2014 Elsevier Ltd. All rights reserved.
    Injury 11/2014; 46(3). DOI:10.1016/j.injury.2014.11.015 · 2.14 Impact Factor
  • Source
    • "For example, Chiu et al. investigated 305 subcapital femoral neck fractures treated by percutaneous pinning and found a high success rate of union without complications (92.5% of patients) [25]. This is in comparison to arthroplasty, which has been shown to have higher infection rates, blood loss, operative time, and mortality rates [26]. In our study, hemiarthroplasty had the highest rate of minor adverse events, and second highest rate of all adverse events. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Hip fractures are one of the most common types of orthopaedic injury with high rates of morbidity. Currently, no study has compared risk factors and adverse events following the different types of hip fracture surgeries. The purpose of this paper is to investigate the major and minor adverse events and risk factors for complication development associated with five common surgeries for the treatment of hip fractures using the NSQIP database. Using the ACS-NSQIP database, complications for five forms of hip surgeries were selected and categorized into major and minor adverse events. Demographics and clinical variables were collected and an unadjusted bivariate logistic regression analyses was performed to determine significant risk factors for adverse events. Five multivariate regressions were run for each surgery as well as a combined regression analysis. A total of 9640 patients undergoing surgery for hip fracture were identified with an adverse events rate of 25.2% (n=2433). Open reduction and internal fixation of a femoral neck fracture had the greatest percentage of all major events (16.6%) and total adverse events (27.4%), whereas partial hip hemiarthroplasty had the greatest percentage of all minor events (11.6%). Mortality was the most common major adverse event (44.9-50.6%). For minor complications, urinary tract infections were the most common minor adverse event (52.7-62.6%). Significant risk factors for development of any adverse event included age, BMI, gender, race, active smoking status, history of COPD, history of CHF, ASA score, dyspnoea, and functional status, with various combinations of these factors significantly affecting complication development for the individual surgeries. Hip fractures are associated with significantly high numbers of adverse events. The type of surgery affects the type of complications developed and also has an effect on what risk factors significantly predict the development of a complication. Concerted efforts from orthopaedists should be made to identify higher risk patients and prevent the most common adverse events that occur postoperatively. Copyright © 2014 Elsevier Ltd. All rights reserved.
    Injury 10/2014; 2(4). DOI:10.1016/j.injury.2014.10.051 · 2.14 Impact Factor
Show more