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Computed tomographic evaluation of the proximal femur: A predictive classifcation in displaced femoral neck fracture management

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Abstract

Background

Femoral neck fracture is truly an enigma due to the high incidence of avascular necrosis and nonunion. Different methods have been described to determine the size of the femoral head fragment, as a small head has been said to be associated with poor outcome and nonunion due to inadequate implant purchase in the proximal fragment. These methods were two dimensional and were affected by radiography techniques, therefore did not determine true head size. Computed tomography (CT) is an important option to measure true head size as images can be obtained in three dimensions. Henceforth, we subjected patients to CT scan of hip in cases with displaced fracture neck of femur. The study aims to defne the term “small head or inadequate size femoral head” objectively for its prognostic signifcance.

Materials and Methods

70 cases of displaced femoral neck fractures underwent CT scan preoperatively for proximal femoral geometric measurements of both hips. Dual energy X-ray absorptiometry scan was done in all cases. Patients were treated with either intertrochanteric osteotomy or lag screw osteosynthesis based on the size of the head fragment on plain radiographs.

Results

The average femoral head fragment volume was 57 cu cm (range 28.3-84.91 cu cm; standard deviation 14 cu cm). Proximal fragment volume of >43 cu cm was termed adequate size (type I) and of ≤43 cu cm as small femoral head (type II). Fractures which united (n = 54) had a relatively large average head size (59 cu cm) when compared to fractures that did not (n = 16), which had a small average head size (49 cu cm) and this difference was statistically signifcant. In type I fractures union rate was comparable in both osteotomy and lag screw groups (P > 0.05). Lag screw fxation failed invariably, while osteotomy showed good results in type II fractures (P < 0.05).

Conclusion

Computed tomography scan of the proximal femur is advisable for measuring true size of head fragment. An objective classifcation based on the femoral head size (type I and type II) is proposed. Osteosynthesis should be the preferred method of treatment in type I and osteotomy or prosthetic replacement is the method of choice for type II femoral neck fractures.

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References

  1. Ravikumar KJ, Marsh G. Internal fixation versus hemiarthroplasty versus total hip arthroplasty for displaced subcapital fractures of femur–13 year results of a prospective randomised study. Injury 2000;31:793–7.

    Article  CAS  PubMed  Google Scholar 

  2. Parker MJ, Raghavan R, Gurusamy K. Incidence of fracture-healing complications after femoral neck fractures. Clin Orthop Relat Res 2007;458:175–9.

    PubMed  Google Scholar 

  3. Lee KB, Howe TS, Chang HC. Cancellous screw fixation for femoral neck fractures: One hundred and sixteen patients. Ann Acad Med Singapore 2004;33:248–51.

    PubMed  CAS  Google Scholar 

  4. Bjørgul K, Reikerås O. Outcome of undisplaced and moderately displaced femoral neck fractures. Acta Orthop 2007;78:498–504.

    Article  PubMed  Google Scholar 

  5. Stappaerts KH, Broos PL. Internal fixation of femoral neck fractures. A followup study of 118 cases. Acta Chir Belg 1987;87:247–51.

    PubMed  CAS  Google Scholar 

  6. Frihagen F, Figved W, Madsen JE, Lofthus CM, Støen RØ, Nordsletten L. The treatment of femoral neck fractures. Tidsskr Nor Laegeforen 2010;130:1614–7.

    Article  PubMed  Google Scholar 

  7. Raaymakers EL. Fractures of the femoral neck: A review and personal statement. Acta Chir Orthop Traumatol Cech 2006;73:45–59.

    PubMed  Google Scholar 

  8. Kyle RF. Operative techniques of fixation for femoral neck fractures in young adults. Tech Orthop 1986;1:33.

    Article  Google Scholar 

  9. Brown TI, Court-Brown C. Failure of sliding nail-plate fixation in subcapital fractures of the femoral neck. J Bone Joint Surg Br 1979;61-B:342–6.

    Article  CAS  PubMed  Google Scholar 

  10. Lu-Yao GL, Keller RB, Littenberg B, Wennberg JE. Outcomes after displaced fractures of the femoral neck. A meta-analysis of one hundred and six published reports. J Bone Joint Surg Am 1994;76:15–25.

    PubMed  CAS  Google Scholar 

  11. Nikolopoulos KE, Papadakis SA, Kateros KT, Themistocleous GS, Vlamis JA, Papagelopoulos PJ, et al. Long term outcome of patients with avascular necrosis, after internal fixation of femoral neck fractures. Injury 2003;34:525–8.

    Article  CAS  PubMed  Google Scholar 

  12. Lykke N, Lerud PJ, Strømsøe K, Thorngren KG. Fixation of fractures of the femoral neck. A prospective, randomised trial of three Ullevaal hip screws versus two Hansson hook-pins. J Bone Joint Surg Br 2003;85:426–30.

    Article  CAS  PubMed  Google Scholar 

  13. Elmerson S, Sjöstedt A, Zetterberg C. Fixation of femoral neck fracture. A randomized 2-year followup study of hook pins and sliding screw plate in 222 patients. Acta Orthop Scand 1995;66:507–10.

    Article  CAS  PubMed  Google Scholar 

  14. Huang HK, Su YP, Chen CM, Chiu FY, Liu CL. Displaced femoral neck fractures in young adults treated with closed reduction and internal fixation. Orthopedics 2010;33:873.

    PubMed  Google Scholar 

  15. Magu NK, Singh R, Mittal R, Garg R, Wokhlu A, Sharma AK. Osteosynthesis and primary valgus intertrochanteric osteotomy in displaced intracapsular fracture neck of femur with osteoporosis in adults. Injury 2005;36:110–22.

    Article  CAS  PubMed  Google Scholar 

  16. Bray TJ, Smith-Hoefer E, Hooper A, Timmerman L. The displaced femoral neck fracture. Internal fixation versus bipolar endoprosthesis. Results of a prospective, randomized comparison. Clin Orthop Relat Res 1988; 230:127–40.

    Google Scholar 

  17. Alho A, Benterud JG, Rønningen H, Høiseth A. Prediction of disturbed healing in femoral neck fracture. Radiographic analysis of 149 cases. Acta Orthop Scand 1992;63:639–44.

    PubMed  CAS  Google Scholar 

  18. Brown JT, Abrami G. Transcervical femoral fracture. A review of 195 patients treated by sliding nail-plate fixation. J Bone Joint Surg Br 1964;46:648–63.

    Article  CAS  PubMed  Google Scholar 

  19. Rajan DT, Parker MJ. Does the level of an intracapsular femoral fracture influence fracture healing after internal fixation? A study of 411 patients. Injury 2001;32:53–6.

    Article  CAS  PubMed  Google Scholar 

  20. Barnes R, Brown JT, Garden RS, Nicoll EA. Subcapital fractures of the femur. A prospective review. J Bone Joint Surg Br 1976;58:2–24.

    Article  CAS  PubMed  Google Scholar 

  21. Singh M, Nagrath AR, Maini PS. Changes in trabecular pattern of the upper end of the femur as an index of osteoporosis. J Bone Joint Surg Am 1970;52:457–67.

    Article  CAS  PubMed  Google Scholar 

  22. Garden RS. The significance of good reduction in medial fractures of the femoral neck. Proc R Soc Med 1970;63:1122.

    PubMed  PubMed Central  CAS  Google Scholar 

  23. Kavakli A, Ogeturk M, Yildirim H, Karakas S, Karlidag T, Sarsilmaz M. Volume assessment of age-related conversion of the tympanic cavity by helical computerized tomography scanning. Saudi Med J 2004;25:1378–81.

    PubMed  Google Scholar 

  24. Magu NK, Rohilla R, Singh R, Tater R. Modified Pauwels’ intertrochanteric osteotomy in neglected femoral neck fracture. Clin Orthop Relat Res 2009;467:1064–73.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: Treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am 1969;51:737–55.

    Article  CAS  PubMed  Google Scholar 

  26. D’aubigne RM, Postel M. Functional results of hip arthroplasty with acrylic prosthesis. J Bone Joint Surg Am 1954;36-A:451–75.

    Article  PubMed  Google Scholar 

  27. Ficat RP, Arlet J. Treatment of bone ischemia and necrosis. In: Hungerford DS, editor. Ischemia and Necroses of Bone. Baltimore, Maryland: Williams and Wilkins; 1980. p. 171–82.

    Google Scholar 

  28. Sandhu HS, Sandhu PS, Kapoor A. Neglected fractured neck of the femur: A predictive classification and treatment by osteosynthesis. Clin Orthop Relat Res 2005;431:14–20.

    Article  Google Scholar 

  29. Per Linton G. Types of displacement in fractures of the femoral neck. J Bone Joint Surg 1949:31-B:184.

    Article  Google Scholar 

  30. Rogmark C, Carlsson A, Johnell O, Sernbo I. A prospective randomised trial of internal fixation versus arthroplasty for displaced fractures of the neck of the femur. Functional outcome for 450 patients at two years. J Bone Joint Surg Br 2002;84:183–8.

    PubMed  CAS  Google Scholar 

  31. Blomfeldt R, Törnkvist H, Ponzer S, Söderqvist A, Tidermark J. Comparison of internal fixation with total hip replacement for displaced femoral neck fractures. Randomized, controlled trial performed at four years. J Bone Joint Surg Am 2005;87:1680–8.

    PubMed  Google Scholar 

  32. Parker MJ, White A, Boyle A. Fixation versus hemiarthroplasty for undisplaced intracapsular hip fractures. Injury 2008;39:791–5.

    Article  PubMed  Google Scholar 

  33. Bhandari M, Devereaux PJ, Tornetta P 3rd, Swiontkowski MF, Berry DJ, Haidukewych G, et al. Operative management of displaced femoral neck fractures in elderly patients. An international survey. J Bone Joint Surg Am 2005;87:2122–30.

    Article  PubMed  Google Scholar 

  34. Tidermark J, Ponzer S, Svensson O, Söderqvist A, Törnkvist H. Internal fixation compared with total hip replacement for displaced femoral neck fractures in the elderly. A randomised, controlled trial. J Bone Joint Surg Br 2003;85:380–8.

    Article  CAS  PubMed  Google Scholar 

  35. Jain NB, Losina E, Ward DM, Harris MB, Katz JN. Trends in surgical management of femoral neck fractures in the United States. Clin Orthop Relat Res 2008;466:3116–22.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Singh MP, Aggarwal AN, Arora A, Dhammi IK, Singh J. Unstable recent intracapsular femoral neck fractures in young adults: Osteosynthesis and primary valgus osteotomy using broad dynamic compression plate. Indian J Orthop 2008;42:43–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  37. Garden RS. Stability and union in subcapital fractures of the femur. J Bone Joint Surg Br 1964;46:630–47.

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Radiology, PGIMS, Rohtak, Haryana, India

    Sarita Magu

  2. Department of Orthopaedics, PGIMS, Rohtak, 124 001, Haryana, India

    Narender Kumar Magu, Rajesh Kumar Rohilla, Amit Batra, Abhishek Jaipuria & Amanpreet Singh

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  1. Narender Kumar Magu
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  2. Sarita Magu
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  3. Rajesh Kumar Rohilla
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  4. Amit Batra
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  6. Amanpreet Singh
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Correspondence to Narender Kumar Magu.

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Magu, N.K., Magu, S., Rohilla, R.K. et al. Computed tomographic evaluation of the proximal femur: A predictive classifcation in displaced femoral neck fracture management. IJOO 48, 476–483 (2014). https://doi.org/10.4103/0019-5413.139857

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