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Minimally displaced and basicervical femoral neck fractures: treatment and outcome
Umeå University, Faculty of Medicine, Department of Diagnostics and Intervention. Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Orthopaedics.ORCID iD: 0000-0003-4615-7276
2024 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Minimalt dislocerade och basocervikala lårbenshalsfrakturer : behandling och utfall (Swedish)
Abstract [en]

Although femoral neck fractures (FNFs) are common injuries, optimal treatment methods have not yet been established. FNFs disproportionately affect the ageing population and are associated with high disability and mortality. Since Garden’s classification was introduced in 1961, hip arthroplasty has emerged as the preferred method for treating displaced FNFs in older patients. However, for undisplaced or minimally displaced FNFs, internal fixation has been the prevailing treatment option, regardless of biological age and activity. Reoperation rates after internal fixation have been reported, ranging from 8% to 19%. Reducing treatment failures and subsequent re-operations is of clinical significance to improve care for this vulnerable patient population. Several treatment options, such as internal fixation and arthroplasty, have been proposed to manage basicervical FNFs. However, the number of available reports on clinical outcomes is limited.

Paper 1 is a register-based observational cohort study of the panorama of FNFs in Sweden based on data from the Swedish Fracture Register (SFR), allowing us to include a large number of FNFs for analysis. Data on age, sex, seasonal variation, trauma mechanism and location, fracture type, treatment and mortality are presented.

Paper 2 is an observational cohort study based on data from the SFR. All basicervical FNFs between 2011 and 2020 and entered into SFR at the participating sites (Sunderbyn, Umeå, Östersund, Karlstad, Uppsala and Göteborg) were screened. A review of radiographs and medical records was performed. We found basicervical FNFs to be difficult to classify accurately. Furthermore, undisplaced basicervical FNFs have a low re-operation rate when treated with internal fixation compared to displaced basicervical FNFs.

Paper 3 is an observational cohort study based on data from three centres (Umeå, Skellefteå and Danderyd) with a consecutive series of undisplaced FNFs treated with internal fixation. This study investigated the association between dorsal and anterior tilt on the lateral radiograph and the outcome after internal fixation. We found that dorsal tilt >20° and anterior tilt >10° increased the risk of treatment failure.

Paper 4 is an observational cohort study based on data from the SFR. We identified a cohort of stress-induced FNFs and reviewed patient medical records to verify a correct diagnosis and identify treatment failures. The study sought to depict the panorama of stress-induced FNFs and document instances of treatment failures. We found low mortality rates, a biphasic age distribution and a large proportion of displaced FNFs.

Paper 5 is a case series of 93 occult FNFs treated with internal fixation. A consecutive series of occult FNFs from four centres were included (Umeå, Skellefteå, Danderyd, Malmö). The treatment failure rate after internal fixation was analysed, and it was shown that 6% led to treatment failure.

Place, publisher, year, edition, pages
Umeå: Umeå University, 2024. , p. 101
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2327
Keywords [en]
Trauma, hip fracture, femoral neck fracture, stress-fracture, basi-cervical fracture, treatment, outcome
National Category
Orthopaedics
Research subject
Medicine; Orthopaedics
Identifiers
URN: urn:nbn:se:umu:diva-231676ISBN: 978-91-8070-505-9 (print)ISBN: 978-91-8070-506-6 (electronic)OAI: oai:DiVA.org:umu-231676DiVA, id: diva2:1912140
Public defence
2024-12-06, Bergasalen, Södra Entrén, Norrlands Universitetssjukhus, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2024-11-15 Created: 2024-11-11 Last updated: 2024-11-11Bibliographically approved
List of papers
1. Epidemiology, classification, treatment, and mortality of adult femoral neck and basicervical fractures: an observational study of 40,049 fractures from the Swedish Fracture Register
Open this publication in new window or tab >>Epidemiology, classification, treatment, and mortality of adult femoral neck and basicervical fractures: an observational study of 40,049 fractures from the Swedish Fracture Register
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2021 (English)In: Journal of Orthopaedic Surgery and Research, E-ISSN 1749-799X, Vol. 16, no 1, article id 561Article in journal (Refereed) Published
Abstract [en]

Background: Although femoral neck fractures (FNFs) are common in orthopedic departments, optimal treatment methods remain in dispute. There are few large nationwide studies, including basicervical FNFs (bFNFs), on epidemiology, treatment, and mortality. This nationwide study aims to describe the epidemiology, fracture classification, current treatment regimens, and mortality of undisplaced and minimally displaced (Garden I–II, uFNF), displaced (Garden III–IV, dFNF) and bFNFs in adults.

Methods: All FNFs, including bFNFs with a registered injury date between 1 April 2012 and 31 December 2020, were included in this observational study from the Swedish Fracture Register (SFR). Data on age, sex, injury mechanism, fracture classification, primary treatment, and seasonal variation were analyzed.

Results: Some 40,049 FNFs were registered in the SFR. The mean age of the patients in the register was 80.3 (SD 11) years and 63.8% (25,567) were female. Of all FNFs, 25.0% (10,033) were uFNFs, 63.4% (25,383) dFNFs, and 11.6% (4,633) bFNFs. Non-surgical treatment was performed in 0.6% (261) of the patients. Internal fixation (IF) (84.7%) was the main treatment for uFNFs and arthroplasty (87.3%) for dFNFs. For bFNFs, IF (43.8%) and hip arthroplasty (45.9%) were performed equally often. Of the 33,105 patients with a 1-year follow-up mortality at 1-year was 20.6% for uFNF, 24.3% for dFNF, and 25.4% for bFNF.

Conclusion: The main treatment of uFNFs is IF with screws or pins. Hip arthroplasty is the predominant treatment for dFNF. bFNF are more common than previously reported and treated with IF or arthroplasty, depending on patient age. These results may help health care providers, researchers and clinicians better understand the panorama of FNFs in Sweden.

Level of Evidence: IV, retrospective cohort study.

Place, publisher, year, edition, pages
BioMed Central (BMC), 2021
National Category
Orthopaedics
Research subject
Orthopaedics
Identifiers
urn:nbn:se:umu:diva-187758 (URN)10.1186/s13018-021-02701-1 (DOI)000696246600004 ()34526047 (PubMedID)2-s2.0-85115091873 (Scopus ID)
Available from: 2021-09-21 Created: 2021-09-21 Last updated: 2024-11-11Bibliographically approved
2. Basicervical femoral neck fractures: an observational study derived from the Swedish fracture register
Open this publication in new window or tab >>Basicervical femoral neck fractures: an observational study derived from the Swedish fracture register
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2024 (English)In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 95, p. 250-255Article in journal (Refereed) Published
Abstract [en]

BACKGROUND AND PURPOSE: Limited research has been conducted on basicervical femoral neck fractures (bFNFs). The importance of displacement in clinical outcomes remains unclear. We aimed to characterize patient demographics, degree of displacement, treatment, treatment failures, and reoperations in a cohort of fractures from the Swedish Fracture Register (SFR).

METHODS: 1,260 fractures in 1,185 individuals ≥ 60 years who had a bFNF registered in the SFR at 6 orthopedic departments from 2011 to 2020 were screened through radiographic review. The final sample included 291 patients with a confirmed bFNF. The medical records of these 291 patients were reviewed. We assessed baseline characteristics, initial fracture dislocation, treatment methods, tip-apex distance, failures, reoperations, and mortality.

RESULTS: The mean age was 82 years (range 60-101, 55% women). 98 (34%) were undisplaced and 193 (66%) displaced. All patients underwent operative treatment. In the undisplaced group 95 (97%) patients received internal fixation (IF) and 3 (3%) had primary hip arthroplasty. In the displaced group 149 (77%) received IF and 41 (21%) had primary hip arthroplasty. 33 (11%) suffered treatment failure. When treating an undisplaced bFNF with IF, only 3 (3%) experienced treatment failure, in contrast to the 24 (16%) failure rate for a displaced bFNF.

CONCLUSION: Undisplaced bFNFs have a low failure rate when treated with IF. For displaced bFNF treated with IF the failure rate is considerably higher. There is a need for further investigation of classification, treatment, and outcome of bFNF.

Place, publisher, year, edition, pages
Medical Journals Sweden, 2024
Keywords
Basal femoral neck fracture, Basicervical femoral neck fracture, Hip, Trauma
National Category
Orthopaedics
Identifiers
urn:nbn:se:umu:diva-224686 (URN)10.2340/17453674.2024.40503 (DOI)38775110 (PubMedID)2-s2.0-85195173305 (Scopus ID)
Available from: 2024-05-23 Created: 2024-05-23 Last updated: 2024-11-11Bibliographically approved
3. Preoperative anterior and posterior tilt of garden I-II femoral neck fractures predict treatment failure and need for reoperation in patients over 60 years
Open this publication in new window or tab >>Preoperative anterior and posterior tilt of garden I-II femoral neck fractures predict treatment failure and need for reoperation in patients over 60 years
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2021 (English)In: JBJS Open Access, ISSN 2472-7245, Vol. 6, no 4, article id e21.00045Article in journal (Refereed) Published
Abstract [en]

Background: The purpose of the present study was to estimate the effect of preoperative fracture tilt and to scrutinize the effect of anterior tilt on the risk of treatment failure in patients with Garden Type-I and II femoral neck fractures that are treated with internal fixation.

Methods: A retrospective multicenter study was performed on a consecutive series of patients ≥60 years of age who had undergone primary internal fixation for the treatment of Garden Type-I and II femoral neck fractures. The study included 1,505 patients with a minimum follow-up of 2 years. Radiographic assessments encompassed preoperative and postoperative tilt, implant inclination, and treatment failure. Data on reoperation and mortality were collected. The risk of treatment failure was assessed with use of Cox proportional hazard regression analysis.

Results: The study comprised 1,505 patients (71% female) with a median age of 81 years (range, 60 to 108 years). Overall, 234 patients (16%) were classified as having a treatment failure and 251 patients (17%) underwent reoperation. A preoperative anterior tilt of >10° and a posterior tilt of >20° were predictors of treatment failure and reoperation, respectively. Treatment failure occurred in 74 (25%) of 301 patients with a posterior tilt of >20° and in 17 (43%) of 40 patients with an anterior tilt of >10°.

Conclusions: This multicenter cohort study identified a subgroup of patients with Garden Type-I and II femoral neck fractures with an anterior tilt of >10° as having high treatment failure rates and major reoperation rates comparable with those associated with displaced femoral neck fractures. A preoperative posterior tilt of >20° increases the risk of treatment failure, and the potential benefit of arthroplasty in this subgroup of patients remains to be further investigated.

Level of Evidence: Prognostic Level III. See Instructions to Authors for a complete description of levels of evidence.

Place, publisher, year, edition, pages
The Journal of Bone and Joint Surgery, 2021
National Category
Orthopaedics
Identifiers
urn:nbn:se:umu:diva-189401 (URN)10.2106/JBJS.OA.21.00045 (DOI)001113919300023 ()34746632 (PubMedID)2-s2.0-85125055272 (Scopus ID)
Note

In thesis with title "Pre-operative anterior and posterior tilt of garden I-II femoral neck fractures predict treatment failure and need for reoperation in patients over 60 years".

Available from: 2021-11-10 Created: 2021-11-10 Last updated: 2024-11-11Bibliographically approved
4. Stress fractures of the femoral neck in adults: an observational study on epidemiology, treatment, and reoperations from the Swedish Fracture Register
Open this publication in new window or tab >>Stress fractures of the femoral neck in adults: an observational study on epidemiology, treatment, and reoperations from the Swedish Fracture Register
Show others...
2022 (English)In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 93, p. 413-416Article in journal (Refereed) Published
Abstract [en]

BACKGROUND AND PURPOSE: Stress fractures of the femoral neck (sFNFs) are uncommon injuries. Studies on sFNFs are rare. We describe the demographics, classification, treatment, reoperation rates, and mortality in a cohort of sFNF patients from the Swedish Fracture Register (SFR).

PATIENTS AND METHODS: We included 146 patients ≥ 18 years of age with an sFNF registered in the SFR between 2011 and 2020. The cohort was linked with the Swedish Arthroplasty Register and reviewed using medical records and radiographs. We assessed the presence of disorders of bone remodeling, duration of symptoms, fracture classification, treatment, reoperations, and mortality.

RESULTS: The mean age was 58 years (21-96), 75% were women and the median duration of symptoms was 23 days (1-266). 40% of patients had disorders of bone remodeling. 54% were undisplaced (uFNF), 30% displaced (dFNF), and 16% basicervical (bFNF). 14% of patients < 60 years were treated nonoperatively, by internal fixation (IF) in 77% and by arthroplasty in 10%. Patients ≥ 60 years were treated nonoperatively in 10%, IF in 40%, and arthroplasty in 49%. Nonoperative treatment was reserved for uFNFs or bFNFs, resulting in 35% receiving late surgery. The overall secondary or late surgery rate was 19%. Mortality was 2% at 90 days and increased to 3% at 1 year.

INTERPRETATION: sFNF has a biphasic age distribution. One-third of patients presented with a displaced FNF and those managed nonoperatively for an undisplaced sFNF were at risk of late surgery. The mortality rates for patients with these injuries was low.

Place, publisher, year, edition, pages
Medical Journals Sweden, 2022
Keywords
Arthroplasty, Femoral Neck Fracture, Fractures, Hip, Stress fracture
National Category
Orthopaedics
Identifiers
urn:nbn:se:umu:diva-193840 (URN)10.2340/17453674.2022.2460 (DOI)000790823500062 ()35417029 (PubMedID)2-s2.0-85128114910 (Scopus ID)
Funder
Region VästerbottenRegion Skåne
Available from: 2022-04-14 Created: 2022-04-14 Last updated: 2024-11-11Bibliographically approved
5. Clinical outcomes of patients with Garden I and II femoral neck fractures as verified on MRI: a retrospective case series
Open this publication in new window or tab >>Clinical outcomes of patients with Garden I and II femoral neck fractures as verified on MRI: a retrospective case series
Show others...
2022 (English)In: BMC Musculoskeletal Disorders, E-ISSN 1471-2474, Vol. 23, no 1, article id 144Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Between 2 to 10% of non-displaced femoral neck fractures (nFNF) cannot be diagnosed on plain radiographs and require further imaging investigation to be detected or verified. These fractures are referred to as occult hip fractures. This study aimed to report treatment failures, reoperations and mortality in a consecutive series of occult femoral neck fractures (FNF) treated with internal fixation (IF).

METHODS: A retrospective multicenter study was performed based on a consecutive series of patients aged ≥ 60 years with an occult magnetic resonance imaging (MRI) verified Garden I and II FNF sustained after a trauma and treated with primary IF. We included 93 patients with a minimum 2-year follow-up. Radiographic assessment encompassed pre- and postoperative tilt, implant inclination, MRI and treatment failure. Data on reoperation and mortality were collected. Treatment failure was defined as fixation failure, nonunion, avascular necrosis or posttraumatic osteoarthritis.

RESULTS: The study comprised of 93 patients (72% women, 67/93) with a mean age of 82 (range, 60-97) years. Overall, 6 (6%) patients had major reoperations. 2 (2%) had minor reoperations. One-month mortality was 7%, 1-year mortality was 20% and 2-year mortality was 31%.

CONCLUSION: This multicenter cohort study identifies a subgroup of elderly patients with MRI verified Garden I and II FNFs sustained after trauma, i.e. occult fractures. These fractures seem to have a lower complication rate compared to nFNF identified on plain radiographs.

LEVEL OF EVIDENCE: Prognostic Level V. See Instructions to Authors for a complete description of levels of evidence.

Place, publisher, year, edition, pages
Springer Nature, 2022
National Category
Orthopaedics
Identifiers
urn:nbn:se:umu:diva-192458 (URN)10.1186/s12891-022-05088-0 (DOI)000754358700001 ()35151282 (PubMedID)2-s2.0-85124636621 (Scopus ID)
Available from: 2022-02-14 Created: 2022-02-14 Last updated: 2024-11-11Bibliographically approved

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