Initial displacement as a risk factor for avascular necrosis of the femoral head in pediatric femoral neck fractures: a review of one hundred eight cases

Wang, Wentao; Li, Yiqiang; Guo, Yunfei; Li, Ming; Mei, Haibo; Shao, Jingfan; Qiu, Xin; Li, Jin; Canavese, Federico; Chen, Shunyou

doi:10.1007/s00264-019-04429-4

Cited by 17 publications

(21 citation statements)

References 32 publications

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“…An unhealed fracture is subsequently prone to further fixation failure as well as FNS. In addition, fracture displacement is predictive for the occurrence of AVN, which is consistent with previous findings [12][13][14][15] . A digital-subtraction angiographic study showed that vessel damage rates in Garden III and IV types could reach as high as 72.7% −100% [2] .…”

Section: Discussionsupporting

confidence: 92%

“…Demographic characteristics, including age and sex, were collected from patients' medical records. Preoperative medical condition including ISS (Injury Severity Score), general comorbidities, combined fractures, and fracture severity including initial displacement (evaluated by Garden classification) [12][13][14][15] , Pauwels angle [3] , and reduction quality [ 13 , 16 ], was evaluated and determined by two independent surgeons using standard methods; a senior surgeon verified these determinations. These parameters were compared as baseline information to explore the possible selection bias between two fixation groups, and incorporated as confounding parameters in the analysis.…”

Section: Study Design and Patientsmentioning

confidence: 99%

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Long-term differences in clinical prognosis between crossed- and parallel-cannulated screw fixation in vertical femoral neck fractures of non-geriatric patients

Jiang

Shi

Cai

et al. 2021

Injury

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Background and Purpose: Vertical femoral neck fractures (VFNFs) are one of the most difficult fractures to stabilize, with high non-union (17%), avascular necrosis (AVN, 21%), and femoral neck shortening (FNS, 29.0%) rates. The objective of this investigation was to directly compare the long-term clinical complication rates of VFNFs repaired by crossed (Alpha fixation) or parallel screws in non-geriatric patients. Patients and Methods:We conducted a retrospective comparative study of VFNFs in patients ( < 60 years) between January 2014 and December 2017, with at least 2 years of follow-up. VFNFs were fixed with either three parallel screws (G-TRI) or augmented with a crossed screw (G-ALP). Confounding variables included age, gender, initial displacement, ISS (Injury Severity Score), general comorbidities, combined fractures, Pauwels angle, reduction quality. Complications, including non-union, AVN of the femoral head and FNS were compared as outcome indicators. Risk factors associated with these variables were further analysed using multivariate analysis.Results: A total of 157 patients (97 G-TRI; 60 G-ALP) met inclusion criteria. G-ALP had a significantly lower rate of FNS (8.3% vs. 28.9%, p = 0.039) than that of G-TRI. non-union (3.3% vs. 11.3%), AVN (21.7% vs. 25.8%), and reoperation rates (21.7% vs. 23.7%) were lower in G-ALP than G-TRI but was not statistically significant. Multivariate analyses showed significant relationships between NU and unacceptable reduction quality (OR = 7.610; 1.823-31.770, adjusted-p = 0.015); between AVN and initial displacement (Garden III and IV) (OR = 7.885; 1.739-35.744, adjusted-p = 0.021); and between FNS and screw configuration (OR = 5.713; 1.839-17.743, adjusted-p = 0.009). Conclusion:For the treatment of VFNFs, satisfactory reduction still remains the key surgical goal that prevents NU, while the incidence of AVN strongly depends on the initial displacement at the time of injury. Crossed screws were associated with a markedly lower FNS rate than parallel screws, which promote further randomised controlled trials to establish a guideline for optimal fixation selection in VFNFs.

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Section: Discussionsupporting

confidence: 92%

Section: Study Design and Patientsmentioning

confidence: 99%

Long-term differences in clinical prognosis between crossed- and parallel-cannulated screw fixation in vertical femoral neck fractures of non-geriatric patients

Jiang

Shi

Cai

et al. 2021

Injury

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“…Several studies have reported that the lack of sufficient mechanical stability of the medial column of the femoral neck contributes to an increase in AVN rate in patients with femoral neck fractures due to the increased stress on the femoral head. 5,26 Interestingly, as inferior and anterior retinacular arteries contribute significantly to the blood supply to the femoral head, we found conflicting results. In particular, we detected a significant association between reduced BD AP % and AVN, even though there was no association between BD L % and reduced screw-inferior cortex on AP radiographs and the AVN rate.…”

Section: Discussionmentioning

confidence: 83%

Effect of the Number, Size, and Location of Cannulated Screws on the Incidence of Avascular Necrosis of the Femoral Head in Pediatric Femoral Neck Fractures: A Review of 153 Cases

Wang

Qiu

et al. 2021

Journal of Pediatric Orthopaedics

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Background:The correlation between the number, size, and location of cannulated screws and the incidence of avascular necrosis (AVN) in children with femoral neck fractures treated surgically is uncertain. Methods: We retrospectively reviewed 153 children (mean age: 10.6 ± 3.7 y) with femoral neck fractures treated by internal fixation with 2 (n = 112) or 3 (n = 41) cannulated screws. The severity of initial displacement was divided into incomplete (type I) and complete (type II, angulation <50 degrees; type III, angulation > 50 degrees) fractures. The diameter of the screw was measured and recorded as a percentage of the femoral neck width. The distance (D) between the mid-point of each screw at the base (B) of the femoral neck and at the tip (T) of each screw and the superior and anterior cortices of the femoral neck, respectively, were measured on anteroposterior (AP) and lateral (L) radiographs. Values were expressed as the ratio between the measured distance and the width of the femoral neck (BD AP %, TD AP %, BD L %, and TD L %). The correlation between the number, size, and location of the screws and AVN was analyzed. Results: Patients with type II of initial displacement treated with 2 cannulated screws had a lower AVN rate (21.4%) than those treated with 3 screws (44.8%) (P = 0.027). Screw diameter (19%) in patients with AVN was larger than (17%) in patients without AVN (P < 0.001); patients with AVN had a lower BD AP % (48.6%) than those without AVN (56.4%) (P < 0.001). Screw size and BD AP % were risk factors for AVN (P < 0.05). Further, screw diameter > 16.5% and BD AP % <51.6% of the femoral neck width were the cutoff values for an increased AVN rate (P < 0.05). Conclusions: Patients treated with 2 cannulated screws showed a lower rate of AVN than patients treated with 3 screws. Screws of larger size and screws closer to the piriformis fossa on AP radiographs increased the risk of AVN in children with femoral neck fractures treated surgically. Level of Evidence: Level III.

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“…Compared with conservative treatment, operative treatment with internal fixation yields fewer postoperative complications and better outcomes and has been accepted by most surgeons [16,17]. Therefore, in our series, surgical treatment with internal fixation was used for each case, even in fractures without displacement [18,19], whereas the association of conservative treatment with the rate of complications was not evaluated.…”

Section: Discussionmentioning

confidence: 99%

Analysis of risk factors for complications after femoral neck fracture in pediatric patients

et al. 2020

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Background: Pediatric femoral neck fracture is a rare injury but yields frequent complications. However, there is a paucity of data regarding the risk factors for these complications. Purpose: The present article reports the rate of complications after femoral neck fracture in pediatric patients and investigates the possible risk factors. Methods: We retrospectively reviewed 44 children (mean age of 9.0 years, range from 2 to 14 years) who were surgically treated for femoral neck fracture in a single trauma center with a mean follow-up of 57.75 months (range from 11 to 224 months). Related clinical factors were recorded and analyzed by multivariable logistic regression. Results: Fracture displacement or Delbet-type fracture had no relation to the injury mechanism. However, younger children experienced severe trauma, combined injury, and low fracture location more than older individuals did. Children with combined injuries were more likely to have a longer waiting time for surgical reduction. Common complications included avascular necrosis (AVN) in 14 cases, nonunion of fracture in 2 cases, coxa vara in 4 cases, and premature physeal closure (PPC) in 7 cases. Only the Delbet type was an independent predictor of AVN (OR = 0.14, p = 0.030). Inadequate reduction was associated with higher rates of coxa vara (OR = 33.19, p = 0.032). Epiphysis penetration in children younger than 10 years old increased the rate of PPC (p = 0.032). No significant risk factor was found for fracture nonunion. Conclusion: For femoral neck fracture in pediatric patients, both the injury mechanism and fracture characteristics have age-related distributions. Early reduction should be carried out as early as possible based on the safe condition of the child, but for younger children, transepiphyseal fixation should be avoided. AVN may be intrinsic to injury characteristics rather than resulting from the choice of treatment mode.

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Initial displacement as a risk factor for avascular necrosis of the femoral head in pediatric femoral neck fractures: a review of one hundred eight cases

Cited by 17 publications

References 32 publications

Long-term differences in clinical prognosis between crossed- and parallel-cannulated screw fixation in vertical femoral neck fractures of non-geriatric patients

Long-term differences in clinical prognosis between crossed- and parallel-cannulated screw fixation in vertical femoral neck fractures of non-geriatric patients

Effect of the Number, Size, and Location of Cannulated Screws on the Incidence of Avascular Necrosis of the Femoral Head in Pediatric Femoral Neck Fractures: A Review of 153 Cases

Analysis of risk factors for complications after femoral neck fracture in pediatric patients

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