The influence of precise surgical technique on the clinical outcome of internal fixation for displaced femoral neck fractures is an under-reported and potential confounding factor in randomized studies involving internal fixation as a treatment modality. Two experienced surgeons blindly rated internal fixation techniques on the perioperative radiographs of 102 patients selected for internal fixation in a prospective multicenter 2-year followup study. Overall technical, fracture reduction, and implant positioning ratings were given according to instruction. One or both raters assigned an inadequate overall rating in 25% of patients. There was a correlation with 2-year clinical internal fixation failure for overall technique and fracture reduction rating. Implant positioning did not correlate with 2-year internal fixation failure. Correlation increased if both raters agreed on inadequate technique. One inadequate rating indicated a problem could arise, whereas two inadequate ratings strengthened this problem likelihood. Adjudication of technique by independent rater(s) is useful, may have clinical implications, and should be performed routinely in future studies involving internal fixation in patients with displaced femoral neck fractures.
[Show abstract][Hide abstract] ABSTRACT: We wanted to assess a new technique for augmentation of parallel screws in internal fixation of displaced femoral neck fractures with a bis-GMA-based composite delivered around the screw head. Twenty-one consecutive patients admitted with displaced femoral neck fractures were operated with internal fixation with two parallel Olmed screws augmented with the composite, and followed for 24 months. The composite was introduced through the lumen of the cannulated screws and deposited in the femoral head around the threaded part of the screws. The procedure of augmenting was technically feasible and operation time was on average 33 min. Eleven patients were re-operated due to healing complications within 24 months. There were five redisplacements, four non-unions and two cases of avascular necrosis. Histological examination of four extracted femoral heads showed fragmentation of the composite into small particles with foreign-body response with giant cells and macrophages along with granulation tissue formation and low grade inflammation. The method of augmentation was technically easy, but the failure rate was high and the fragmentation of the composite with inflammatory response found on histology is noteworthy.
[Show abstract][Hide abstract] ABSTRACT: To compare the therapeutic effect of cannulated screws fixation at different time points through different reduction methods on the healing of displaced femoral neck fractures.
From January 1997 to September 2007, 240 patients with displaced femoral neck fracture were treated, including 121 males and 119 females aged 22-79 years old (average 56 years old). All cases were fresh and close fractures. According to the fractured part, there were 133 cases of subcapital fracture, 64 of transcervical fracture and 43 of basal fracture. According to Garden classification, there were 105 cases of type III and 135 of type IV. Cannulated screws fixation was performed on all the patients, and the time from injury to operation was 6 hours to 7 days. Fifty-five cases received closed reduction and 59 cases received limited open reduction as emergency treatment, while 65 cases received closed reduction and 61 cases received limited open reduction as selective operation. Different groups were compared in terms of the healing rate of fracture, the excellent and good rate of reduction as well as the excellent and good rate of fixation.
There was no significant difference between the closed reduction and the limited open reduction in terms of operation time and bleeding volume (P > 0.05). Postoperatively, all wounds healed by first intention, no infection was observed, avascular necrosis of femoral head occurred in 44 cases, and the rate of avascular necrosis of femoral head in the limited open reduction at emergency group was less than that of other 3 groups (P < 0.01). All the patients were followed up for 12-72 months (average 38 months), 193 cases got fracture healing at 10-23 months after operation (average 14 months). For the closed reduction as emergency operation group, the limited open reduction as emergency operation group, the closed reduction as selective operation group, and the limited open reduction as selective operation group, the healing rate of fracture was 74.55%, 91.53%, 69.23% and 86.89%, respectively; the excellent and good rate of reduction was 73.73%, 94.92%, 70.77% and 91.80%, respectively; the excellent and good rate of fixation was 76.36%, 93.22%, 73.85% and 88.52%, respectively. The healing rate of fracture, the excellent and good rate of reduction as well as the excellent and good rate of fixation in the limited open groups were higher than that of the closed reduction groups (P < 0.01), and there was no significant difference between the emergency operation groups and the selective operational groups (P > 0.05).
The reduction methods have significant influences on the healing of fractures after cannulated screws fixation of the displaced femoral neck fracture, and the operation time has no obvious effect on fracture healing.
Zhongguo xiu fu chong jian wai ke za zhi = Zhongguo xiufu chongjian waike zazhi = Chinese journal of reparative and reconstructive surgery 04/2009; 23(4):440-3.
[Show abstract][Hide abstract] ABSTRACT: To conduct a systematic review and synthesize the evidence for the effects of surgical treatments for subcapital and intertrochanteric/subtrochanteric hip fractures on patient-focused outcomes for elderly patients.
MEDLINE, Cochrane databases, Scirus, and ClinicalTrials.gov, and expert consultants. We also manually searched reference lists from relevant systematic reviews.
High quality quasi-experimental design studies were used to examine relationships between patient characteristics, type of fracture, and patient outcomes. Randomized controlled trials were used to examine relationships between type of surgical treatment and patient outcomes. Patient mortality was examined with Forest plots. Narrative analysis was used for pain, quality of life (QoL), and functional outcomes due to inconsistently measured and reported outcomes.
Mortality does not appear to differ by device class, or by devices within a class. Nor, on the whole, do pain, functioning, and QoL. Some internal fixation devices may confer earlier return to functioning over others for some patients, but such gains are very short lived. Very limited results suggest that subcapital hip fracture patients with total hip replacements have improved patient outcomes over internal fixation, but it is unclear whether these results would continue to hold if the analyses included the full complement of relevant covariates. Age, gender, prefracture functioning, and cognitive impairment appear to be related to mortality and functional outcomes. Fracture type does not appear to be independently related to patient outcomes. Again, however, the observational literature does not include the full complement of potential covariates and it is uncertain if these results would hold.
Several factors limit our ability to definitively answer the key questions posed in this study using the existing literature. Limited perspectives lead to incomplete sets of independent variables included in analyses. Specific populations are poorly defined and separated for comparative study. Fractures with widely varying biomechanical problems are often lumped together. Outcome variables are inconsistently measured and reported, making it very difficult to aggregate or even compare results. If future high quality trials continue to support the evidence that differences in devices are short term at best, within the first few weeks to few months of recovery, policy implications involve establishing the value of a shorter recovery relative to the cost of the new device. As the literature generally focuses on community dwelling elderly patients, more attention needs to be directed toward understanding implications of surgical treatment choices for the nursing home population.
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