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What makes fixation of femoral neck fractures fail? A systematic review and meta-analysis of risk factors

Published:November 15, 2022DOI:https://doi.org/10.1016/j.injury.2022.11.042

      Highlights

      • Female, ≥50 years, smoking, inadequate reduction and treatment with cannulated screws are predictors for reoperation in patients with dFNF.
      • Female patients with a dFNF above 50 years of age that smoke have a high risk of failure of treatment.
      • The results of this study can be used to substantiate future algorithms and guidelines for treatment of dFNF.

      Abstract

      Introduction

      This systematic review aims to provide an overview of predictors for failure of treatment of displaced femoral neck fracture (dFNF) with internal fixation and quantify their risk of fixation failure in a meta-analysis.

      Patients and methods

      PubMed, Embase, Web of Science, Cochrane Library, and EMCare were searched for original studies published from January 2000, including adult patients with an internally fixated dFNF, that reported data on predictors for fixation failure defined as revision surgery due to non-union, avascular femoral head necrosis or cut-out of implant. RevMan version 5 software was used to pool univariable Odds Ratio's (OR) for predictors of fixation failure by means of a random effects model.

      Results

      This review included 16 articles (15 articles cohort studies and one randomised trial). Twenty-four predictors for fixation failure were identified and analysed, 16 of which were evaluated in just one study. Data of 7 predictors were pooled in a meta-analysis. Female sex (OR 1.78, 95% confidence interval [CI] 1.26–2.52), smoking (OR 3.64, 95% CI 1.68–7.91), age >50 years (OR 3.64, 95% CI 1.68–7.91), inadequate fracture reduction (OR 2.28, 95% CI 1.62–3.22), fixation with cannulated screws (CS) or pins compared to fixed angle devices (OR 2.16, 95% CI 1.03–4.54) were identified as significant predictors for fixation failure.

      Conclusion

      This study can help surgeons to choose the preferred treatment for patients with a dFNF and substantiate future algorithms and guidelines for treatment of FNF.

      Keywords

      Abbreviations:

      dFNF (displaced femoral neck fractures), IF (Internal Fixation), OR (Odds Ratio), CI (Confidence Interval), FNF (Femoral Neck Fracture), AVN (Avascular necrosis), GRADE (The Grading of Recommendations Assessment, Development and Evaluation)
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      References

        • Dahl H.K
        Surgical treatment of femoral neck fractures. The 100-year anniversary.
        Tidsskr Nor Laegeforen. 1994; 114: 3600-3603
        • Bhandari M.
        • Devereaux P.J.
        • Swiontkowski M.F.
        • Tornetta 3rd, P.
        • Obremskey W.
        • Koval K.J.
        • et al.
        Internal fixation compared with arthroplasty for displaced fractures of the femoral neck. A meta-analysis.
        J Bone Joint Surg Am. 2003; 85-A: 1673-1681
        • Sheth N.P.
        • Brown N.M.
        • Moric M.
        • Berger R.A.
        • Della Valle C.J
        Operative treatment of early peri-prosthetic femur fractures following primary total hip arthroplasty.
        J Arthroplasty. 2013; 28: 286-291
        • Evans J.
        • Evans J.
        • Walker R.
        • Blom A.
        • Whitehouse M.
        • Sayers A.
        How long does a hip replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up.
        Lancet. 2019; 393: 647-654
        • Slobogean G.P.
        • Sprague S.A.
        • Scott T.
        • Bhandari M.
        Complications following young femoral neck fractures.
        Injury. 2015; 46: 484-491
        • 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: 183-188
        • Heetveld M.J.
        • Rogmark C.
        • Frihagen F.
        • Keating J.F.
        Internal fixation versus arthroplasty for displaced femoral neck fractures: what is the evidence?.
        J Orthop Trauma. 2009; 23: 395-402
        • Bhandari M.
        • Swiontkowski M.
        Management of acute hip fracture.
        N Engl J Med. 2017; 377: 2053-2062
        • Palm H.
        • Posner E.
        • Ahler-Toftehoj H.U.
        • Siesing P.
        • Gylvin S.
        • Aasvang T.
        • et al.
        High reliability of an algorithm for choice of implants in hip fracture patients.
        Int Orthop. 2013; 37: 1121-1126
        • Swart E.
        • Roulette P.
        • Leas D.
        • Bozic K.J.
        • Karunakar M.
        ORIF or arthroplasty for displaced femoral neck fractures in patients younger than 65 years old: an economic decision analysis.
        J Bone Joint Surg Am. 2017; 99: 65-75
        • Sprague S.
        • Schemitsch E.H.
        • Swiontkowski M.
        • Della Rocca G.J.
        • Jeray K.J.
        • Liew S.
        • et al.
        Factors associated with revision surgery after internal fixation of hip fractures.
        J Orthop Trauma. 2018; 32: 223-230
        • Duckworth A.D.
        • Bennet S.J.
        • Aderinto J.
        • Keating J.F
        Fixation of intracapsular fractures of the femoral neck in young patients: risk factors for failure.
        J Bone Joint Surg Br. 2011; 93: 811-816
        • Dargan D.P.
        • Callachand F.
        • Diamond O.J.
        • Connolly C.K.
        Three-year outcomes of intracapsular femoral neck fractures fixed with sliding hip screws in adults aged under sixty-five years.
        Injury. 2016; 47: 2495-2500
        • Kuo L.T.
        • Lin S.J.
        • Hsu W.H.
        • Peng K.T.
        • Lin C.L.
        • Hsu R.W.
        The effect of renal function on surgical outcomes of intracapsular hip fractures with osteosynthesis.
        Arch Orthop Trauma Surg. 2022; 134: 39-45
        • Schweitzer D.
        • Melero P.
        • Zylberberg A.
        • Salabarrieta J.
        • Urrutia J.
        Factors associated with avascular necrosis of the femoral head and nonunion in patients younger than 65 years with displaced femoral neck fractures treated with reduction and internal fixation.
        Eur J Orthop Surg Traumatol. 2022; 23: 61-65
        • Moher D.
        • Shamseer L.
        • Clarke M.
        • Ghersi D.
        • Liberati A.
        • Petticrew M.
        • et al.
        Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement.
        Syst Rev. 2015; 4 (1-4053-4-1)
        • Schwartsmann C.R.
        • Lammerhirt H.M.
        • Spinelli L.F.
        • Ungaretti Neto A.D.S.
        Treatment of displaced femoral neck fractures in young patients with DHS and its association to osteonecrosis.
        Rev Bras Ortop. 2022; 53: 82-87
        • Kilian M.
        • Csorgo P.
        • Sajter M.
        • Simkovic P.
        • Vajczikova S.
        • Zamborsky R.
        Locking plate fixation with multiple telescoping sliding screws for femoral neck fractures.
        Ortop Traumatol Rehabil. 2018; 20: 493-498
        • Kalsbeek J.H.
        • van Walsum A.D.P.
        • Vroemen J.P.A.M.
        • Janzing H.M.J.
        • Winkelhorst J.T.
        • Bertelink B.P.
        • et al.
        Displaced femoral neck fractures in patients 60 years of age or younger: results of internal fixation with the dynamic locking blade plate.
        Bone Joint J. 2018; 100-B: 443-449
        • Heetveld M.J.
        • Raaymakers E.L.F.B.
        • van Eck-Smit B.L.
        • van Walsun A.D.P.
        • Luitse J.S.K.
        Internal fixation for displaced fractures of the femoral neck.
        J Bone Jt Surg Ser B. 2005; 87: 367-373
        • Ouzzani M.
        • Hammady H.
        • Fedorowicz Z.
        • Elmagarmid A.
        Rayyan-a web and mobile app for systematic reviews.
        Syst Rev. 2016; 5 (210-016-0384-4)
        • Foroutan F.
        • Guyatt G.
        • Zuk V.
        • et al.
        GRADE guidelines 28: use of GRADE for the assessment of evidence about prognostic factors: rating certainty in identification of groups of patients with different absolute risks.
        J Clin Epidemiol. 2020; 121: 62-70
        • Hayden J.A.
        • van der Windt D.A.
        • Cartwright J.L.
        • Cote P.
        • Bombardier C.
        Assessing bias in studies of prognostic factors.
        Ann Intern Med. 2013; 158: 280-286
      1. The Cochrane Collaboration. Review Manager (RevMan) [Computer program]. 2020, Version 5.4.

      2. Higgins J.P.T., Thomas J., Chandler J., Cumpston M., Li T., Page M.J., et al. Cochrane handbook for systematic reviews of interventions version 6.0. 2019 01 July 2019:04 June 2020-www.training.cochrane.org/handbook.

        • Campenfeldt P.
        • Al-Ani A.
        • Hedstrom M.
        • Ekstrom W.
        Low BMD and high alcohol consumption predict a major re-operation in patients younger than 70 years of age with a displaced femoral neck fracture-A two -year follow up study in 120 patients.
        Injury. 2018; 49: 2042-2046
        • Heetveld M.J.
        • Raaymakers E.
        • Luitse J.S.K.
        • Gouma D.J.
        Rating of internal fixation and clinical outcome in displaced femoral neck fractures - a prospective multicenter study.
        Clin Orthop. 2006; : 207-213
        • Hoshino C.M.
        • Christian M.W.
        • O'Toole R.V.
        • Manson T.T.
        Fixation of displaced femoral neck fractures in young adults: fixed-angle devices or Pauwel screws?.
        Injury. 2016; 47: 1676-1684
        • Huang T.W.
        • Hsu W.H.
        • Peng K.T.
        • Lee C.Y.
        Effect of integrity of the posterior cortex in displaced femoral neck fractures on outcome after surgical fixation in young adults.
        Injury. 2011; 42: 217-222
        • Kalland K.
        • Aberg H.
        • Berggren A.
        • Ullman M.
        • Snellman G.
        • Jonsson K.B.
        • et al.
        Similar outcome of femoral neck fractures treated with Pinloc or Hansson pins: 1-year data from a multicenter randomized clinical study on 439 patients.
        Acta Orthop. 2019; 90: 542-546
        • Kenan S.
        • Gold A.
        • Salai M.
        • Steinberg E.
        • Ankory R.
        • Chechik O.
        Long-term outcomes following reduction and fixation of displaced subcapital hip fractures in the young elderly.
        Isr Med Assoc J. 2022; 17: 341-345
        • Nyholm A.M.
        • Palm H.
        • S holdt H
        • Troelsen A.
        • Gromov K
        Risk of reoperation within 12 months following osteosynthesis of a displaced femoral neck fracture is linked mainly to initial fracture displacement while risk of death may be linked to bone quality: a cohort study from Danish fracture database.
        Acta Orthop. 2020; 91: 1-75
        • Stearns A.T.
        • Jaberoo M.C.
        • Ashraf R.
        • Wheelwright E.F.
        • Maclean A.D
        Displaced intracapuslar hip fractures in the working age alcohol-abusing patient.
        Scott Med J. 2009; 54: 16-20
        • Thein R.
        • Herman A.
        • Kedem P.
        • Chechik A.
        • Shazar N.
        Osteosynthesis of unstable intracapsular femoral neck fracture by dynamic locking plate or screw fixation: early results.
        J Orthop Trauma. 2014; 28: 70-76
        • van Dortmont L.M.
        • Douw C.M.
        • van Breukelen A.M.
        • Laurens D.R.
        • Mulder P.G.
        • Wereldsma J.C.
        • et al.
        Cannulated screws versus hemiarthroplasty for displaced intracapsular femoral neck fractures in demented patients.
        Ann Chir Gynaecol. 2000; 89: 132-137
        • Xiong W.F.
        • Chang S.M.
        • Zhang Y.Q.
        • Hu S.J.
        • Du S.C.
        Inferior calcar buttress reduction pattern for displaced femoral neck fractures in young adults: a preliminary report and an effective alternative.
        J Orthop Surg Res. 2019; 14 (70-019-1109-x)
        • Gardner S.
        • Weaver M.J.
        • Jerabek S.
        • Rodriguez E.
        • Vrahas M.
        • Harris M.
        Predictors of early failure in young patients with displaced femoral neck fractures.
        J Orthop. 2014; 12: 75-80
        • Patterson J.T.
        • Ishii K.
        • Tornetta 3rd, P.
        • Leighton R.K.
        • Friess D.M.
        • Jones C.B.
        • et al.
        Open reduction is associated with greater hazard of early reoperation after internal fixation of displaced femoral neck fractures in adults 18–65 years.
        J Orthop Trauma. 2020; 34: 294-301
        • Marchand L.S.
        • Butler B.
        • McKegg P.
        • DeLeon G.
        • O'Hara N.N.
        • Lebrun C.T.
        • et al.
        Fixed angle device comparison in young femoral neck fractures: dynamic hip screw vs dynamic helical hip system.
        Injury. 2022; 53: 590-595
        • Tuck S.P.
        • Pearce M.S.
        • Rawlings D.J.
        • Birrell F.N.
        • Parker L.
        • Francis R.M.
        Differences in bone mineral density and geometry in men and women: the Newcastle thousand families study at 50 years old.
        Br J Radiol. 2005; 78: 493-498
        • Gilligan I.
        • Chandraphak C.
        • Mahakkanukrauh P.
        Femoral neck-shaft angle in humans: variation relating to climate, clothing, lifestyle, sex, age and side.
        J Anat. 2013; 223: 133-151
        • Ji M.
        • Yu Q.
        Primary osteoporosis in postmenopausal women.
        Chronic Dis Transl Med. 2015; 1: 9-13
        • Wang W.
        • Zhao T.
        • Geng K.
        • Yuan G.
        • Chen Y.
        • Xu Y.
        Smoking and the pathophysiology of peripheral artery disease.
        Front Cardiovasc Med. 2021; 8704106
        • Hernigou J.
        • Schuind F.
        Tobacco and bone fractures a review of the facts and issues that every orthopaedic surgeon should know.
        Bone Joint Res. 2019; 8: 255-265
        • Samsami S.
        • Saberi S.
        • Sadighi S.
        • Rouhi G.
        Comparison of three fixation methods for femoral neck fracture in young adults: experimental and numerical investigations.
        J Med Biol Eng. 2015; 35: 566-579
        • Bonnaire F.A.
        • Weber A.T.
        Analysis of fracture gap changes, dynamic and static stability of different osteosynthetic procedures in the femoral neck.
        Injury. 2002; 33: 24-32
        • Schottel P.C.
        • Blankstein M.
        • Sprague S.
        • Swiontkowski M.
        • Bzovsky S.
        • Bhandari M.
        • et al.
        Optimal technical factors during operative management of low energy femoral neck fractures.
        J Orthop Trauma. 2020; 35: 92-99
        • Jenkins P.J.
        • Ramaesh R.
        • Pankaj P.
        • Patton J.T.
        • Howie C.R.
        • Goffin J.M.
        • et al.
        A micro-architectural evaluation of osteoporotic human femoral heads to guide implant placement in proximal femoral fractures.
        Acta Orthop. 2013; 84: 453-459
        • Wu C.C.
        Using biomechanics to improve the surgical technique for internal fixation of intracapsular femoral neck fractures.
        Chang Gung Med J. 2010; 33: 241-251
        • Panteli M.
        • Rodham P.
        • Giannoudis P.V.
        Biomechanical rationale for implant choices in femoral neck fracture fixation in the non-elderly.
        Injury. 2015; 46: 445-452
        • Wright D.J.
        • Bui C.N.
        • Ihn H.E.
        • McGarry M.H.
        • Lee T.Q.
        • Scolaro J.A.
        Posterior inferior comminution significantly influences torque to failure in vertically oriented femoral neck fractures: a biomechanical study.
        J Orthop Trauma. 2020; 34: 644-649
        • Rawall S.
        • Bali K.
        • Upendra B.
        • Garg B.
        • Yadav C.S.
        • Jayaswal A.
        Displaced femoral neck fractures in the young: significance of posterior comminution and raised intracapsular pressure.
        Arch Orthop Trauma Surg. 2012; 132: 73-79
        • Elgeidi A.
        • El Negery A.
        • Abdellatif M.S.
        • El Moghazy N
        Dynamic hip screw and fibular strut graft for fixation of fresh femoral neck fracture with posterior comminution.
        Arch Orthop Trauma Surg. 2017; 137: 1363-1369
        • Alho A.
        • Benterud J.G.
        • Ronningen H.
        • Hoiseth A.
        Prediction of disturbed healing in femoral neck fracture. Radiographic analysis of 149 cases.
        Acta Orthop Scand. 1992; 63: 639-644