MEDICINA (2002) Vol. 38, No. 5 - http://medicina.kmu.lt
505
Treatment results of displaced femoral neck fractures Arūnas Vertelis, Algimantas Petrulis, Viktoras Jermolajevas 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 aspira-
tion 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:
[email protected]
506
Arūnas Vertelis, Algimantas Petrulis, Viktoras Jermolajevas
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: good 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%). Meth-
ods 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 1st group the osteosynthesis was done using up-to-date fixators and in the
Table 1. Treatment methods, 1997-1999 Treatment methods 3–6.5 mm screws Smith-Petersen nails plus 6.5 mm srew Smith-Petersen Hansson DHS Rydell Total arthroplasty CITO Angulated plate Ullevall Hemiarthroplasty Not operated: skeletal traction Total
1997
1998
1999
Total
3 25 41 23 5 1 4 5 4 2 15 3
24 38 9 8 2 22 7 0 2 1 16 4
21 8 1 0 0 6 11 0 0 51 10 0
48 71 51 31 7 29 22 5 6 54 41 7
131
133
108
372
Table 2. Use of up-to-date and outdated fixators, 1997-1999 Methods Up-to-date fixators Outdated fixators
Ullevall, Hansson, 3–6.5 mm sr. Rydell, Smith-Petersen, CITO, angulated plates, DHS
1997
1998
1999
Total
53 56
71 35
80 7
204 98
MEDICINA (2002) Vol. 38, No. 5 - http://medicina.kmu.lt
Treatment results of displaced femoral neck fractures
2nd 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
