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14. Cemil Kayali Turkish Journal of Trauma & Emergency Surgery Ulus Travma Acil Cerrahi Derg 2008;14(3):226-230 Original Article Klinik Çal›flma Complications of internally fixed femoral neck fractures Femur boyun kırıklarında internal tespit sonrası komplikasyonlar Cemil KAYALI,1 Haluk A⁄Ufi,1 Mustafa ARSLANTAfi,2 Ali TURGUT1 BACKGROUND AMAÇ Femoral neck fractures in young patients are the emergent in- Genç hastalarda femur boyun k›r›klar› kesin redüksiyon ve juries that require precise reduction and stable fixation. stabil tespiti gerektiren acil yaralanmalard›r. Tüm geliflmelere Despite all advances, nonunion and avascular necrosis (AVN) ra¤men femur bafl› avasküler nekrozu (AVN) ve kaynamama of the femoral head are the major complications necessitating kurtar›c› ameliyatlar gerektiren en önemli komplikasyonlard›r. salvage procedures. In this retrospective series, we evaluated Bu geriye dönük çal›flmada, internal tespit yap›lan femur bo- the complications of internally fixed femoral neck fractures. yun k›r›klar›n›n komplikasyonlar› de¤erlendirildi. METHODS GEREÇ VE YÖNTEM This study consisted of 32 cases that had displaced femoral Deplase femur k›r›kl› 32 hasta çal›flmaya dahil edildi. Baz› neck fractures. Although some of them admitted to hospital hastalar ilk yaralanmadan sekiz saat sonra hastanemize more than 8 hours after initial trauma, all underwent internal baflvurmalar›na ra¤men en erken zamanda ameliyata al›nd›lar. fixation as early as possible. All the fractures were reduced Aç›k redüksiyon gerektiren befl hasta d›fl›nda tüm olgulara and fixed by closed reduction under fluoroscopy control. kapal› redüksiyon ve tespit uyguland›. AVN, Ficat ve Arlet However, 5 cases needed open reduction. AVN was determi- kriterlerine göre de¤erlendirildi. Klinik de¤erlendirme Harris ned by using Ficat and Arlet criteria. Clinical evaluation was taraf›ndan tan›mlanan puanlama sistemine göre yap›ld›. performed based on the scoring system described by Harris. RESULTS BULGULAR Mean follow-up period was 49±29 months (range 24-126). Ortalama izlem süresi 49±29 ayd› (da¤›l›m 24-126). On üç ol- AVN of the femoral head was observed in 13 cases (40%). guda femur bafl› avasküler nekrozu belirlendi (%40); ancak However, only 5 of them had unsatisfactory clinical results re- yaln›zca befl olguda yetersiz sonuca ba¤l› total kalça protezi quiring salvage surgery as total hip replacement. Nonunion of uyguland›. Befl olguda da kaynamama saptand›. Yap›lan ista- fracture was seen in 5 cases. In the statistical analysis, a nega- tistiksel analizde, AVN derecesi ve klinik puanlar aras›nda ters tive correlation was observed between the degree of AVN and iliflki belirlendi. Ameliyata al›nma süresi ile geç komplikas- clinical findings. We found no correlation between the dura- yonlar aras›nda iliflki saptanmad›. tion of the preoperative period and late complications. CONCLUSION SONUÇ AVN is the most common complication of displaced femoral Deplase femur boyun k›r›klar›n›n en s›k komplikasyonu neck fractures. However, less than half of these cases require AVN’dir. Ancak olgular›n yar›dan az›na kurtar›c› ameliyat salvage procedures. Total hip replacement is the preferred gerekmifltir. Bu olgularda total kalça protezi uygun tedavi treatment option for these cases. seçene¤idir. Key Words: Avascular femoral head necrosis; femoral neck fracture; Anahtar Sözcükler: Femur bafl› avasküler nekrozu; femur boyun internal fixation; nonunion. k›r›¤›; internal tespit; kaynamama. 1Department of Orthopaedics and Traumatology, Tepecik Education an d 1Tepecik E¤itim ve Araflt›rma Hastanesi, Research Hospital, Izmir; 2Department of Orthopaedics and Traumatology, Ortopedi ve Travmatoloji Klini¤i, ‹zmir; 2Özel Medicana Hastanesi, Medicana Hospital, Istanbul, Turkey. Ortopedi ve Travmatoloji Klini¤i, ‹stanbul. Correspondence (‹letiflim): Cemil Kayal›, M.D. 6445 Soka k , No: 10, D: 4, Karfl›yaka 35550 ‹zmir, Turkey. Tel: +90 - 232 - 3 3 7 0 0 26 Fax ( F a k s ): +90 - 232 - 4 3 3 0 7 5 6 e-mail ( e - p o s t a ) : c e m i l k a y a l i @ y a h o o . c o m 226 Complications of internally fixed femoral neck fractures Femoral neck fractures are generally observed at maneuver was performed to reduce the fracture.[9] two different peaks: first, due to high-energy trau- Fractures that could be reduced were fixed by 6.5 ma in relatively young adults, and second, due to mm cannulated screws under C armed fluoroscopy low-energy trauma in osteoporotic elderly patients. control. On the other hand, capsulotomy through la- Common treatment alternatives for these cases are teral approach was performed to reduce and fix the internal fixation and arthroplasty options.[1-3] Many fracture in 5 cases in whom closed reduction was factors including fracture type, patient age, and not possible. All the cases were mobilized with medical status affect the choice of treatment. crutches after removing urinary catheters and suc- P a r t i c u l a r l y, femoral neck fracture in young tion drains 48 hours postoperatively without patients is an emergency condition and necessitates weight-bearing. We used antibiotic prophylaxis and precise reduction and rigid internal fixation. low molecular heparin for 2 and 7 days, respecti- Although new developments in operation tech- vely. Patients were encouraged regarding weight- niques and implant technology have been achieved, bearing with respect to painless status and evidence avascular necrosis (AVN) of the femoral neck and of bony healing clinically and radiologically. Mean nonunion are the most common and morbid com- full weight-bearing time was 11±1 weeks (range 9- plications.[4-6] It has been reported that although not 13). Patients were followed up at 6-week intervals all the cases with AVN need arthroplasty proce- in the first half year and at 12-week intervals in the dures secondarily, nonunion is a morbid complica- second in the outpatient clinic (Fig. 1a-c). To eva- tion that usually requires salvage surgery.[6,7] luate AVN, the radiographic criteria described by [10] In this retrospective study, we evaluated the Ficat and Arlet were used. Clinical evaluation complications and clinical results of the subjects was performed according to Harris Hip Scoring treated by internal fixation. (HHS) criteria as 90 to 100 points: excellent, 80 to 90: good, 70 to 80: fair, and below 70: poor.[11] Frac- MATERIALS AND METHODS ture classification was performed using the criteria [8] From January 1995 to December 2003, 304 described by Garden. Statistical analysis with patients with femoral neck fracture admitted to our Spearman correlation test was performed using clinic. Fifty-three cases were treated via internal SPSS for Windows program. fixation (15 dynamic hip screw, 38 only cannulated RESULTS screw fixation). Of the remaining cases, 232 were treated via arthroplasty options due to older age, Mean follow-up period was 49±29 months (ran- and 19 were treated conservatively due to poor ge 24-126). The average age of cases was 44.4±13 medical condition or fracture type. years (range 14-60). According to Garden classifi- cation, there were 19 type III and 13 type IV frac- We lost 2 of 38 cases; therefore, we were able to tures. The average interval from injury to operation evaluate 36 patients in this study treated by cannu- was 18±22 hours (range 2-84). lated screw fixation. However, 4 of them had undis- placed fracture pattern as Garden II and were Superficial wound infection in 1 case and uri- excluded.[8] Therefore, this current series comprised nary tract infection in 3 cases were early complica- 32 subjects. Twenty-five of the cases were male. tions. They were treated with oral antibiotics. In 3 The etiologies of fractures were as follows: 5 traf- cases, we observed reduction loss during outpatient fic accidents, 2 occupational injuries and 25 falls on clinic follow-ups in the early period (9%). One of the fracture site. Three cases had additional injuries them fell on his operated side despite warnings. as rib, radius and contralateral femur fractures. These cases underwent revision as re-reduction and re-fixation. One case healed satisfactorily, but 2 did Patients admitted to our hospital were transport- not, requiring total hip replacement procedure later ed to the operating room under emergency condi- due to nonunion. During the follow-up period, tions after obtaining conventional radiographs. All nonunion in another 3 cases was observed. Total cases were operated as soon as possible although hip arthroplasty was performed for these 5 cases some were admitted to the hospital more than 8 due to nonunion. hours after trauma. All the operations were per- formed in the supine position. First, Leadbetter With respect to late complications, AVN was ob- Cilt - Vol. 14 Say› - No. 3 227 Ulus Travma Acil Cerrahi Derg served in 13 patients (40%). Five of these cases had tive due to its facilitating early weight-bearing, unsatisfactory clinical results and required total hip although it carries higher mortality rates. However, arthroplasty. There were 10 required salvage proce- patients below 60, suffering from high-energy trau- dures overall, for an incidence of 31%. ma such as traffic and occupational accidents or sports injuries, are usually treated via internal fixa- We determined a negative correlation between tion. It was reported that early internal fixation is the degree of AVN and clinical findings at the last [12] follow-up (r= -0.46, p= 0.007). The limb lengths of the gold standard for relatively young cases. In both extremities at the last follow-up were meas- addition, some authors have claimed that femoral ured, and we found a mean 2±6.5 mm length dis- neck fracture in young patients should be consid- crepancy as shortening (range +15 - [-25]). ered as vascular injury. In this case, intervention should comprise prompt reduction of fracture and The effect of the interval from initial trauma to early internal fixation under emergency condi- operation on nonunion and AVN was analyzed.
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