Lars T. Nilsson

Femoral neck fracture fixation with hook-pins. 2-year results and learning curve in 626 prospective cases.

We performed a prospective 2-year follow-up study of 626 consecutive femoral neck fractures treated with closed reduction and hook-pin fixation in all cases. The woman:man ratio was 2.9:1, the displaced:undisplaced fracture ratio 2.6:1. Mean patient age was 78 (18-100) years. The first 476 fractures were operated on by one of six surgeons with special interest in the technique, while the remaining operations were performed by any of the 35 surgeons in the department, all specialists in orthopedic surgery. Mortality within two years was 31 percent. Healing complications (redisplacement, nonunion or segmental femoral head collapse) in the total material/survivors only were for undisplaced fractures 5/7 percent, for displaced fractures 30/41 percent and for the total material 23/32 percent. According to life-table analysis, the complication rate in the total material at two years was 24 percent. The rate of secondary arthroplasty for healing complications was 13/19 percent. For displaced fractures, as well as for the total material, the group of specially interested surgeons had better results than the department as a whole.

Two-year follow-up of femoral neck fractures: Comparison of osteosynthesis methods

For 14 consecutive months, all 152 femoral neck fracture patients greater than or equal to 50 years of age admitted to the Lund University Hospital were operated on with two hook-pins if born on an uneven date and a four-flanged nail if born on an even date. A clinical 2-year follow-up revealed a 35 per cent mortality. Among survivors, radiographic healing complications were seen in undisplaced fractures in 1/13 pinned and 5/14 nailed (p greater than 0.05) and in displaced fractures in 12/36 pinned and 23/32 nailed (p less than 0.01). This outcome correlated well with the early postoperative scintimetry. Reoperation within 2 years had been performed for seven pinned and 19 nailed fractures. In hook-pinning, thus, less than one patient out of 12 needed a reoperation with THR within 2 years. This figure is interpreted as strongly favouring hook-pinning before arthroplasty as the primary procedure in femoral neck fracture.

Hemarthrosis in undisplaced cervical fractures: Tamponade may cause reversible femoral head ischemia

In eight undisplaced intracapsular fractures of the femoral neck, an intracapsular hematoma was diagnosed by computed tomography. 99mTc-MDP scintimetry revealed markedly reduced or absent blood supply to the head of femur. The intracapsular pressure was 23 (2.7-43) kPa with the hip in neutral position. Following aspiration of 12 (0.5-36) ml of blood, pressure was reduced to zero, and postaspiration scintimetry revealed restitution of blood supply to the femoral head. Hip joint tamponade in these patients has caused femoral head ischemia, reversible by aspiration.

Factors predicting healing complications in femoral neck fractures 138 patients followed for 2 years

We have previously studied the radiographic outcome of femoral neck fracture osteosynthesis with either two hook-pins or a four-flanged nail performed by a small group of surgeons with special interest in the methods. In 138 femoral neck fractures a backwards stepwise logistic regression analysis was used to study the significance of preoperative fracture-related factors, intraoperative factors and the osteosynthesis. The development of non-union/redisplacement and segmental collapse of the femoral head was influenced by fracture displacement (P 0.001) and method of osteosynthesis (P 0.007). The postoperative scintimetric ratio was influenced by the method of osteosynthesis (P 0.0003), fracture displacement (P 0.004) and by the presence of a posterior fragment (P 0.03). Reduction of the fracture and positioning of the osteosynthesis were to a large extent within the accepted limits. This may explain why the previously well documented negative effects of malpositioning of the osteosynthesis and inferior reduction were not demonstrated to influence the rate of healing-complications. We conclude that neither patient age, sex nor preoperative fracture variables, with the exception of the extent of fracture displacement, can be used to predict radiographic healing-complications in femoral neck fractures.

Nailing of femoral neck fracture: Clinical and sociologic 5-year follow-up of 510 consecutive hips

In a retrospective population-based study, 510 consecutive cervical hip fractures treated by internal fixation with a spring-loaded four-flanged nail, early weight bearing, and social rehabilitation were examined at 5 years after primary nailing. Six (1.6 percent) deep infections occurred. After a new trauma, seven fractures through the nail entrance were seen. Mortality at 2 years was 32 percent and at 5 years 53 percent. With a program for active rehabilitation, 80 percent of the survivors coming from independent living returned to this and remained there. The frequency of reoperations in patients below age 70 years was twice as high as in those over 70. Secondary arthroplasty was performed in 6 percent of the 129 undisplaced fractures and in 25 percent of the 381 displaced fractures. Totally, 67 percent of the fractures had no secondary procedure, not even nail extraction.

Function after primary hemiarthroplasty and secondary total hip arthroplasty in femoral neck fracture

Four to 12 years after primary treatment of femoral neck fracture with hemiarthroplasty in a group of Finnish patients and secondary total hip arthroplasty as a salvage procedure for healing complication after primary osteosynthesis in a group of Swedish patients, function was classified and the Nottingham Health Profile questionnaire was applied. The two groups were comparable with regard to age, sex, and social status. The patients with secondary total hip arthroplasty used walking aids to a lesser extent than the patients with hemiarthroplasty and experienced less problems in several aspects of life. Walking ability was considered unchanged, compared to prefracture, to a larger extent in the secondary total hip arthroplasty group. Thus, secondary total hip arthroplasty in patients with healing complication following primary osteosynthesis gives better long-term functional capacity than that obtained with a primary hemiarthroplasty.

Prognostic precision in postoperative 99mTc-MDP scintimetry after femoral neck fracture

A 2-year follow-up regarding healing complications, such as redisplacement, nonunion, and segmental collapse of the femoral head, was performed in 306 patients operated on for femoral neck fracture and examined with 99mTechnetium-MDP scintimetry within 2 weeks postoperatively. Scintimetric evaluation was performed by selecting regions of interest over the femoral head on the fracture side and the intact side and by comparing the uptake. A femoral head ratio fractured/intact side thus was obtained. Of 199 patients with an intact femoral head uptake (ratio greater than or equal to 1.0), 181 showed no signs of healing complications at 2 years, whereas 18 had developed healing complications. Of 107 cases with a deficient femoral-head uptake (ratio less than 1.0), 96 had developed healing complications within 2 years from the operation, while 11 cases had no signs of radiographic complications. We conclude that 99mTc-MDP scintimetry performed within 2 weeks from femoral neck fracture can predict the outcome of the healing course with a prognostic accuracy of 91 per cent.

Reliability of the prospective data collection protocol of the Swedish Spine Register: Test-retest analysis of 119 patients

Background The Swedish Lumbar Spine Register has been collecting patient-based data since 2000, and more than 80% of all spinal units in Sweden are now including their patients. In a few years, it will produce useful clinical information just as arthroplasty registers have, but to permit proper interpretation of data in the future, the reliability of the protocol must be tested. Methods Between January 2000 and March 2003, a sample of 122 patients was asked to fill in the questionnaire twice: 63 preoperatively and 59 postoperatively. Test-retest reliability was calculated with intra-class correlation coefficient (ICC) or weighted kappa when appropriate. Results Test-retest interval varied (range 0–235 days); in the “worst case scenario”, the lowest ICC for SF-36 was 0.62 for the postoperative RE. Other values were above 0.70; for non-SF variables, ICC was in the range 0.79–0.89. Kappa values for the ordinal outcomes were high (0.74–0.91). Interpretation When separate reliability analysis was performed according to the time interval, a 0–2 days interval produced a significant memory effect; after 3 weeks, the reliability seemed to drop in the preoperative group, whereas results were reproducible up to 9 weeks postoperatively. The protocol studied can reliably detect postoperative improvements between large groups of patients such as in a register.

Function after hook-pin fixation of femoral neck fractures: prospective 2-year follow-up of 191 cases

Totally, 191 consecutive patients with femoral neck fractures during 1984 and 1985 had internal fixation with hook-pins and were prospectively investigated. Within 2 years, 62 patients had died and 47 had developed healing complications, 30 of whom had been treated with total hip replacement. Thus, 82 healed without complication. Forty-one of 47 patients without other handicaps affecting their walking ability considered their gait as good as it was preoperatively; 45 used no walking aids or a cane. Nine of 35 patients with a nonfracture-related disease affecting their walking ability managed to walk with or without a cane; 13 considered their walking ability unaltered compared with their prefracture state. Three of 82 patients complained of pain on walking and 2 of pain at rest. All but 1 could flex their hip 90 degrees or more. We believe that the function after internal fixation of cervical hip fracture with uncomplicated healing is superior to that achieved by primary hip replacement; primary replacement is recommended only in rheumatoid patients with displaced fractures.

Traumatic hip joint tamponade: Two cases with femoral head ischaemia

Two elderly patients had pain after hip trauma with no radiographic evidence of fracture. Computed tomography demonstrated capsular haematoma. Scintimetry revealed femoral head ischaemia. Intracapsular hip joint pressure in extension was 240 and 176 mm Hg, respectively, in neutral position and 280 and 360 mm Hg in internal rotation. The hip joints were aspirated for 8 ml and 5 ml of blood, respectively, leading to pain relief and regained radiotracer uptake in the femoral head. It is concluded that traumatic hip joint tamponade may cause femoral head ischaemia which may be reversed by aspiration.