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The Relationship Between Femoral Neck Fracture in Adult and Avascular Necrosis and Nonunion: a Retrospective Study T

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The Relationship Between Femoral Neck Fracture in Adult and Avascular Necrosis and Nonunion: a Retrospective Study T Annals of Medicine and Surgery 39 (2019) 5–9 Contents lists available at ScienceDirect Annals of Medicine and Surgery journal homepage: www.elsevier.com/locate/amsu The relationship between femoral neck fracture in adult and avascular necrosis and nonunion: A retrospective study T ∗ Saeed Koaban, Raheef Alatassi , Salman Alharbi, Mansour Alshehri, Khalid Alghamdi Security Forces Hospital, Department of Orthopedic Surgery, Riyadh, Saudi Arabia ARTICLE INFO ABSTRACT Keywords: Background: One of the most serious sequelae of femoral neck fractures (FNFs) is avascular necrosis (AVN), and Adult this complication translates to significant morbidity and mortality. This study was conducted to determine the Avascular necrosis relationship between the etiologies and management of FNFs at our institution and the development of AVN or Complications nonunion. Delayed fixation Materials and methods: This study was a retrospective medical chart review of all adult patients admitted and Femoral neck fracture managed for FNF. Nonunion Results: There were a total of 69 FNF patients reviewed. FNF was caused by a fall in 37 patients (53.6%), a road traffic accident in 16 (23.2%), motorcycle and motorbike accidents in 8 (11.6%), and heavy exercise in 8 (11.6%). Twenty-four patients (34.8%) had fixation within 24 h of injury, and 45 (65.2%) went more than 24 h before fixation. The mean RUSH score at 6 months was 21.4 ± 5.1. There were 4 patients (5.8%) with a col- lapsed FNF and 4 patients (5.8%) had a nonunion FNF. AVN was documented in 12 patients (17.4%). Of the 12 patients who had AVN, 8 (66.7%) received fixation within 24 h from the time of the injury, whereas only 4 (33.3%) received fixation more than 24 h after the injury. There was a significant negative correlation between the time of fixation and AVN. Conclusion: We report a 17.4% incidence of AVN over 10 years in patients managed with FNF. AVN was found to be significantly correlated with the mode of injury (fall and RTA among younger male patients). 1. Introduction The radiographic union score for the hip (RUSH) is a score system used to describe healing of femoral neck fractures, particularly among pa- Femoral neck fractures (FNFs) are fractures of the flattened pyr- tients who might require additional surgery, and patients with a 6- amidal bone connecting the femoral head and the femoral shaft. It is not month RUSH score < 18 have a greater probability of undergoing re- common in healthy individuals but common among athletes, military operation [9]. recruits, and young adults because of high energy activities such as Surgical management of FNFs includes open reduction and internal sports and road traffic accidents, in adults because of falls, in women fixation (ORIF), which has some fixation failures [10], primary total hip because of estrogen imbalances, and in patients because of bone mi- arthroplasty (TA), which is cost-effective for displaced FNFs in patients neralization and deficiencies [1–4]. In the USA in 2013, there were a 45–65 years old [10], cannulated screw (CS) fixation for young and reported 146 cases per 100,000 people [5]. Mortality can be as high as middle-aged patients [11], dynamic hip screw fixation (DHS) [12], and 30% in one year, particularly if treatment is delayed over 24 h [6]. hemiarthroplasty [13]. The decision of what type of surgical manage- FNFs are classified using the Garden Classification of ante- ment to use depends on several factors, including displacement of the roposterior radiographs into Types I to IV, where Type I is incomplete femoral neck, presence of hip joint arthritis, age, and other factors [14]. fracture, Type II is complete but non-displaced fracture, Type III is Approximately 24% of patients who had THA underwent revision complete and partially displaced fracture and Type IV is complete and within 5 years because of aseptic loosening, infection and other causes fully displaced femur [7]. Another classification is Pauwel's classifica- [15]. Some surgeons, however, prefer ORIF and some prefer THA for tion, which is a biomechanical classification based on the vertical or- displaced FNFs, particularly among active older patients with Garden ientation of the fracture line and is commonly used to determine the Type III fracture [16]. A case of peritrochanteric fracture was also re- appropriate treatment for FNFs, particularly among younger adults [8]. ported to be successfully operated with a dynamic interlocking ∗ Corresponding author. P.O. Box: 3643, Riyadh, 11481, Saudi Arabia. E-mail address: [email protected] (R. Alatassi). https://doi.org/10.1016/j.amsu.2019.01.002 Received 17 September 2018; Received in revised form 14 January 2019; Accepted 19 January 2019 2049-0801/ © 2019 The Author(s). Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/). S. Koaban et al. Annals of Medicine and Surgery 39 (2019) 5–9 Garden classification, side of injury, time to fixation (in hours), type of Abbreviations reduction, type of implant used, RUSH score (healing), start of weight- bearing activity, development of AVN, and final outcome (whether FNF Femoral neck fracture varus, valgus, displaced or healed). This study was approved by the AVN Avascular necrosis local research ethics committee at our institution and registered in CS Cannulated screw ClinicalTrials.gov. The current paper was written according to the re- DHS Dynamic hip screw cently published STROCSS statement [29]. RTA Road traffic accident Statistical analysis of the data was performed using the Statistical RUSH Radiographic union score for hip Package for Social Sciences (SPSS) version 23.0 (SPSS Incorporated, ORIF Open reduction and internal fixation Armonk, NY, USA). The results are expressed in numbers and percen- tages (for categorical variables) and mean and standard deviation (for continuous variables). Pearson correlations were used to determine the trochanteric gamma nail [17]. correlation between two variables. Independent t-tests were used to One of the most serious sequelae of FNFs is avascular necrosis determine significant differences between two means. A multivariate (AVN), which occurs in 10–45% of patients with FNFs, particularly regression analysis was performed to determine the significant pre- those who have displaced and nonunion FNFs [18]. Nonunion occurs in dictors of AVN. A p-value of < 0.05 was considered statistically sig- almost 20% of FNFs and is more common in men than women, and nificant. common with increasing age [19]. Approximately 33% of displaced FNFs are associated with complications [20]. One study showed that age and type of fixation are not significantly correlated with the in- 3. Results cidence of AVN, but the amount of vascular damage at the time of the fracture determines the development of vascular necrosis [21]. On the There were a total of 69 FNF cases of patients reviewed, 60 (87.0%) other hand, a separate study showed that fracture type and age are the males and 9 (13.0%) females with a mean age of 37.1 ± 15.5 years most significant predictors of the development of AVN [22]. (range: 18–70 years old). There were 37 patients who had comorbid It has been mentioned that time is essential in the management of conditions such as diabetes and hypertension. Four patients (5.8%) FNFs, particularly in the development of AVN. One study showed that claimed to be smokers. Table 1 shows the detailed demographic profile the rates of AVN increase over time when patients underwent surgery of the 69 patients. before 12 h had elapsed to after 12 h from 12.5% to 14.0% [23], while Table 2 shows the details of the FNF injury. FNF was caused by a fall another study showed that a delay of more than 48 h before surgery did in 37 patients (53.6%), a road traffic accident (RTA) in 16 patients not influence the rate of union or the development of AVN when (23.2%), motorcycle and motorbike accidents in 8 patients (11.6%) and compared with operations within 48 h of injury [24]. Some studies heavy exercise in 8 patients (11.6%). Multiple traumas were present in reported that bleeding from the holes of cannulated screws predict the 16 patients (23.2%). There were 8 patients (11.6%) with Grade I development of AVN [25], some due to damage to the blood supply of Garden FNF, 8 patients (11.6%) with Grade II FNF, 20 patients (29.0%) the femoral head brought about by the initial high energy trauma [26] with Grade III FNF, and 33 patients (47.8%) with Grade IV FNF. Forty- and some due to the extent of fracture displacement [27]. Other studies one patients (59.4%) had a right-sided FNF. Twenty-four patients have suggested that FNFs treated using cannulated screws, particularly (34.8%) had fixation within 24 h of injury and 45 (65.2%) had their among middle-aged and elderly patients, have reduced AVN incidence fixation after 24 h of injury. Forty-four patients (63.8%) had a close [28]. Because of these studies, we undertook this study to determine the reduction of the fracture. There were 29 patients (42.0%) who had a relationship between the etiologies and management of FNFs in our dynamic hip screw (DHS), whereas 40 patients (58.0%) had a cannu- institution and its relationship to the development of AVN or nonunion. lated screw (CS). The mean RUSH score at 6 months was 21.4 ± 5.1 (range: 10–28), and the mean full weight-bearing follow-up was 5.6 ± 3.9 months (range: 1–12 months). There were 4 patients (5.8%) 2. Methods with collapsed FNF, and 4 patients (5.8%) had a nonunion FNF.
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