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Comparative Study of Pauwels Type III Femoral Neck Fractures Managed by Short Dynamic Hip Screw with Fibula Bone Graft Or Cannulated Screws in Young Adults

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Comparative Study of Pauwels Type III Femoral Neck Fractures Managed by Short Dynamic Hip Screw with Fibula Bone Graft Or Cannulated Screws in Young Adults 681 Original Article Page 1 of 8 Comparative study of Pauwels type III femoral neck fractures managed by short dynamic hip screw with fibula bone graft or cannulated screws in young adults Zhengqiang Li1#, Xuebin Zhang1#, Zhaowei Li2, Aqin Peng1, Lichuang Zhang1, Yingying Deng1, Lianxin Song1 1Trauma Emergency Center, Third Hospital of Hebei Medical University, Shijiazhuang, China; 2Trauma Orthopedics, Affiliated Hospital of Qinghai University, Xining, China Contributions: (I) Conception and design: Z Li, L Song; (II) Administrative support: L Song; (III) Provision of study materials or patients: Z Li, L Song; (IV) Collection and assembly of data: Z Li, X Zhang, Z Li, A Peng, L Zhang, Y Deng; (V) Data analysis and interpretation: Z Li, X Zhang, Z Li, L Song; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors. #These authors contributed equally to this work as the co-first authors. Correspondence to: Lianxin Song. Trauma Emergency Center, Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, China. Email: [email protected]. Background: The aim of our study was to compare the clinical effect of short dynamic hip screw (DHS) combined with fibula bone graft and short DHS combined with cannulated screws (CS) on the treatment of femoral neck fracture in young adults. Methods: Thirty-five Pauwels type III femoral neck fracture patients between January 2014 and May 2019 were divided into two groups: group A (patients treated with DHS combined with fibula bone graft) and group B (patient treated with DHS combined with CS). The operative time, intraoperative blood loss, fracture healing time and complication of two groups were recorded. Results: There were no significant differences in operative time, intraoperative blood loss in two groups. Fracture healing time in group A (5.28±1.07) was significantly shorter than group B (7.31±1.65). The rate of fracture nonunion (0), femoral head necrosis (0) and withdrawal rate (0) in group A were significantly lower than that in group B (4, 23.5) (4, 23.5) (6, 35.3) (P<0.01). Postoperative Harris function score in group A (95.44±2.57) was higher than group B (87.82±7.79) (P<0.01). Conclusions: DHS combined with fibula bone graft can shorten the healing time of fracture, reduce the rate of bone nonunion and femoral head necrosis, and provide a new treatment method for Pauwels type III femoral neck fracture in young adults. Keywords: Femoral neck fracture; dynamic hip screw (DHS); cannulated screws (CS); fibula bone graft; young adults Submitted Oct 23, 2019. Accepted for publication May 09, 2020. doi: 10.21037/atm-19-3344 View this article at: http://dx.doi.org/10.21037/atm-19-3344 Introduction injuries such as traffic injury, fall injury and so on (3,4). The Pauwels classification (5) is commonly used for femoral It is estimated that the incidence of hip fractures worldwide increases to 2.6 million in 2025 (1). Femoral neck fracture is neck fractures in young patients. one of the most common clinical fractures, accounting for The surgical treatment of femoral neck fracture has 50% of hip fractures (2). The occurrence of femoral neck been developed continuously, which are often fixed with fracture in young adults is usually caused by high-energy cannulated screws (CS), sliding hip screw (SHS), total © Annals of Translational Medicine. All rights reserved. Ann Transl Med 2020;8(11):681 | http://dx.doi.org/10.21037/atm-19-3344 Page 2 of 8 Li et al. Comparative study of Pauwels type III femoral neck fractures arthroplasty (THA), dynamic hip screw (DHS) with or CT and the three-dimensional reconstruction. This study without antirotation screw, DHS with blade instead of was approved by the Medicine Human Experimental ethic screw (DHS-blade) or similar implants (6,7). However, committee of Qinghai University School and all patients there has been no consensus for the optimal therapeutic signed the written informed consent. regimen available in the literature due to the high rates of Inclusion criteria were patients (I) with fresh closed postoperative complications. Currently, DHS combined femoral neck fracture; (II) who were aged 16–65 years; (III) with CS is mainly used in the treatment of Pauwels type III with Pauwels III type femoral neck fracture (Pauwels angle femoral neck fracture in young adults, but 8% of patients >50°) (the Pauwels angle refer to the angle between fracture still suffer from nonunion of bone and necrosis of femoral line and the iliac spine line) (12); (IV) the patient had good head (8-10). hip movement before injury; (V) complete the follow-up. Fibula bone graft has been recommended for the Exclusion criteria were patients (I) with ipsilateral femoral treatment of previous femoral neck fractures and has fracture; (II) with pathological fracture of femoral neck; achieved good clinical results in the treatment of femoral (III) with old femoral neck fracture; (IV) open fracture; neck fractures with nonunion and avascular necrosis of (V) disorders of consciousness, new cerebral infarction and the femoral head (11). However, there are few reports previous hip disease. on the application of fibular transplantation for the All the patients voluntarily underwent short DHS fracture of femoral neck in young adults. In this study, we combined with fibula bone graft or DHS combined with CS introduce a novel treatment of femoral neck fracture that internal fixation. DHS was provided by Tianjin Zhengtian patients treated with DHS combined with fibular graft. (Tianjin, China), CS was provided by Stryker (Stryker, Furthermore, the clinical effect of DHS combined with USA), and fibula strips were all autogenous. fibular graft in the treatment of Pauwels type III femoral neck fracture in young adults was investigated. The main Preoperative preparation objective of this study was to compare the clinical effect of short DHS combined with fibula bone graft and short After admission, routine examination and laboratory tests DHS combined with CS on the treatment of femoral neck were performed, and relevant departments were invited fracture in young adults. We present the following article in to consult and treat related diseases. Preoperative imaging accordance with the STROBE reporting checklist (available examination of the affected side of the hip was performed at http://dx.doi.org/10.21037/atm-19-3344). to timely understand the displacement of the fracture end. No traction was performed on the affected limb before operation. Preoperative routine preventive measurements Methods of infection and deep venous thrombosis of lower limbs was Patients administered. Preoperative routine drugs for pain, swelling and other symptomatic treatment was performed. There Thirty-five adult patients with Pauwels type III femoral were no donor site complications including donor site neck fracture in Third Hospital of Hebei Medical fractures, skin infections, non-healing, and necrosis. University who met the inclusion criteria from January 2014 to May 2019 were retrospectively studied in this study. Operation methods According to the therapeutic regimes, 18 cases were treated with DHS combined with fibula bone graft and thus defined Both operations were performed by Professor Lianxin as the group A, while 17 cases were treated with DHS Song. Patients in both groups were given continuous combined with CS and thus defined as the group B. The epidural anesthesia or general anesthesia and lay on the surgical options were determined by the treating physician. traction bed after satisfactory anesthesia. Under the Seven cases were caused by a fall injures and 11 cases C-arm X-ray fluoroscopy, the method of Leadbetter (13) were caused by traffic accident injuries in group A. Ten or McElvenny (14) is adopted for closed reduction. cases were caused by fall injuries and 7 cases were caused Three-dimensional interactive reduction of femoral by traffic accident injuries in group B. The diagnosis and neck can be used when the reduction was difficult (15). classification were assisted by the clinical examination of Garden’s classification was used and the combination of the injured body, the lateral X-ray of the affected hip joint, anteroposterior (AP) and lateral methods were used to reset © Annals of Translational Medicine. All rights reserved. Ann Transl Med 2020;8(11):681 | http://dx.doi.org/10.21037/atm-19-3344 Annals of Translational Medicine, Vol 8, No 11 June 2020 Page 3 of 8 and restore the femoral anteversion and neck-shaft angle. the fracture breaking end of the fracture became smaller The traction of the affected limb was continued. The area in size, dense, clear in edges, the fracture line disappeared, of routine iodine alcohol disinfection was covered with and trabecular bone passed across the broken ends. At the sterile towel. An approximate 8cm longitudinal incision last follow-up, the Harris hip function scale was used to was made on the affected hip joint. The skin, subcutaneous, score hip function. Preoperative and postoperative visual fascia, and lateral femoral muscle were cut layer by layer, analogue scale (VAS) score were recorded. then subtrochanteric cortex was exposed. The incidence of complications in the two groups was Under the C-arm fluoroscopy, two guide pins were observed and recorded during follow-up, including nail drilled parallel to1 cm above the femoral neck near the withdrawal rate, fracture nonunion and femoral head calcar femorale to fix the fracture of the acetabulum. After necrosis rate. Nonunion of fracture was defined as the depth sounding, a step drill was used to drill holes. After results of reexamination indicating that there was little tapping, a DHS of appropriate length was inserted into the callus at the fracture end, a gap between the bone ends subcortical femoral head for 5–10 mm. A 2-hole dynamic to form a pseudojoint, and no trabecular formation. The hip plate was placed at the distal end of the fracture and two broken ends were atrophic and smooth, and the bone made to adhere to the bone cortex on the lateral side of the marrow cavity was filled with dense bone and occluded.
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