Open Reduction Is Associated With Greater Hazard of Early Reoperation After Internal Fixation of Displaced Femoral Neck Fractures in Adults 18–65 Years

Abstract

Objectives: To determine (1) which factors are associated with the choice to perform an open reduction and (2) by adjusting for these factors, if the choice of reduction method is associated with reoperation. Design: Retrospective cohort study with radiograph and chart review. Setting: Twelve Level 1 North American trauma centers. Patients: Two hundred thirty-four adults 18–65 years of age with an isolated, displaced, OTA/AO type 31-B2 or type 31-B3 femoral neck fracture treated with internal fixation with minimum of 6-month follow-up or reoperation. Exclusion criteria were pathologic fractures, associated femoral head or shaft fractures, and primary arthroplasty. Intervention: Open or closed reduction technique during internal fixation. Main outcome: Cox proportional hazard of reoperation adjusting for propensity score for open reduction based on injury, demographic, and medical factors. Reduction quality was assessed by 3 senior orthopaedic traumatologists as “acceptable” or “unacceptable” on AP and lateral postoperative radiographs. Results: Median follow-up was 1.5 years. One hundred six (45%) patients underwent open reduction. Reduction quality was not significantly affected by open versus closed approach (71% vs. 69% acceptable, P = 0.378). The propensity to receive an open reduction was associated with study center; younger age; male sex; no history of injection drug use, osteoporosis, or cerebrovascular disease; transcervical fracture location; posterior fracture comminution; and surgery within 12 hours. A total of 35 (33%) versus 28 (22%) reoperations occurred after open versus closed reduction (P = 0.056). Open reduction was associated with a 2.4-fold greater propensity-adjusted hazard of reoperation (95% confidence interval 1.3–4.4, P = 0.004). A total of 35 (15%) patients underwent subsequent total hip arthroplasty or hemiarthroplasty. Conclusions: Open reduction of displaced femoral neck fractures in nonelderly adults is associated with a greater hazard of reoperation without significantly improving reduction. Prospective randomized trials are indicated to confirm a causative effect of open versus closed reduction on outcomes after femoral neck fracture. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparison of the clinical efficacy of a femoral neck system versus cannulated screws in the treatment of femoral neck fracture in young adults

“…One of the authors of the present study has previous experience with dynamic hip screw surgery and the short learning curve. FNS uses a nail-in-nail combination to increase anti-rotation stability and overall biomechanical properties, and the FNS power bar is a percussion placement rather than rotational placement of a dynamic hip head nail, avoiding the secondary rotational displacement of the femoral head caused by rotational torque [ 17 ]. The CS method requires three screws to be parallel with one another and to be in an inverted triangle formation, and requires a higher spatial distribution of screws.…”

Use of Intraoperative Multidimensional Fluoroscopy to Assess Femoral Neck Reduction Quality in a Patient with Displaced Femoral Neck Fracture: A Case Report

“…However, opponents of open reduction argue that opening the capsule increases the risk of AVN by potentially damaging the anterior vessels [4]. A recent retrospective cohort study of 274 patients under 65 years of age with displaced FNF demonstrated a 2.4-fold greater hazard of reoperation following open reduction due to a complication such as AVN or non-union [3]. In contrast, a recent meta-analysis including 21 studies comparing open versus closed reduction found no difference in the rates of AVN, non-union or total complications [4].…”

“…Similar techniques have also been demonstrated for evaluating the quality of reductions intra-operatively in the syndesmosis, calcaneus, distal humerus, and distal radius [7-11]. In young FNF, the single most important modifiable treatment variable in predicting positive clinical outcomes and reducing the risk of post-operative complication is the quality of FNF reduction [3]. The application of this imaging technology to evaluating FNF reduction intra-operatively enables the surgeon to utilize closed reduction techniques, limiting the risk of damage to vascular structures, while allowing for critical assessment of FNF reduction.…”

“…Some surgeons believe intraoperative two-dimensional imaging can erroneously lead a surgeon to believe that the reduction The young remains a dilemma for the orthopaedic surgeon. Outcomes in this population are poor, patients experience long-term disability secondary to complications, and frequently require early conversion to total hip arthroplasty [3]. Significant controversy remains on the optimal reduction strategy for this patient population.…”

“…Displaced femoral neck fractures (FNF) in patients 60 years of age or younger are challenging injuries to surgically manage with approximately 20% of patients requiring reoperation for complications such as avascular necrosis (AVN), non-union, malunion, and implant failure [1][2][3]. Although quality of fracture reduction has been shown to be the most consistent predictor of treatment success, controversy remains however on when a closed reduction is adequate or an open reduction is necessary to obtain a superior clinical outcome [4].…”