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
: 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.
Available from: Anne Marie Nyholm
- "As an example, Anand et al. used data from the The Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) to show that over 250 new hip and knee prosthesis were introduced to the Australian market in a five year period between 2003 and 2007 alone, with none of the newer prostheses having lower revision rates and one third actually having higher revision rates compared to the established ones at 5-year follow- up, thus supporting the use of the well-established, older products. Similar findings have been made in trauma surgery as shown in a study by Berkes et al.who reported catastrophic results after use of a novel implant for proximal femoral fractures. Another argument to support systematic monitoring of implants through registries is the fact that due to the high mortality and often cognitive impairment seen in patients with proximal femoral fractures, larger RCTs with representative populations are notoriously difficult to conduct and therefore may not be the optimal method of evaluating implants in fracture related surgery. "
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Evaluation of the long-term performance of implants used in trauma surgery relies on post-marked clinical studies since no registry based implant assessment exists. The purpose of this study was to evaluate the evidence of performance of implants currently used for treating proximal femoral fractures (PFF) in Denmark.
PubMed was searched for clinical studies on primary PFF with follow-up ≥12 months, reporting implant-related failure and evaluating one of following: DHS, CHS, HipLoc, Gamma3, IMHS, InterTan, PFN, PFNA or PTN. Limits: English language and publication date after 1st of January 1990.
All studies were evidence level II or III. 30 publications for SHS were found: 13 of CHS, 15 of DHS and 2 of HipLoc. In total CHS was evaluated in 1110 patients (900 prospectively), DHS in 2486 (567 prospectively) and HipLoc in 251 (all prospectively). Fifty-four publications for nails were found: 13 of Gamma3, 7 of IMHS, 5 of InterTan, 10 of PFN, 24 of PFNA and 0 of PTN. In total Gamma3 was evaluated in 1088 patients (829 prospectively), IMHS in 1543 (210 prospectively), InterTan in 595 (585 prospectively), PFN in 716 (557 prospectively), PFNA in 1762 (1018 prospectively) and PTN in 0.
The clinical evidence behind the current implants used for proximal femoral fractures is weak considering the number of implants used worldwide. Sporadic evaluation is not sufficient to identify long term problems. A systematic post market surveillance of implants used for fracture treatment, preferable by a national register, is necessary in the future.
Available from: Trude Basso
- "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. "
Available from: sciencedirect.com
- ". Although locked plating constructs have been proposed as a potential solution to prevent femoral neck fracture shortening , clinical results of locked plate fixation for femoral neck fractures have been suboptimal  . 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 . "
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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.
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