Preoperative Anterior and Posterior Tilt of Garden I-II Femoral Neck Fractures Predict Treatment Failure and Need for Reoperation in Patients Over 60 Years

Abstract

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.

Evaluation of the Posterior Tilt Angle in Predicting Failure of Nondisplaced Femoral Neck Fractures After Internal Fixation: A Systematic Review

“…Difficulty obtaining perfect lateral radiographs to measure the PTA because of soft-tissue envelope or other possibilities should be considered. Although a high intraobserver and interobserver reliability is reported in measuring the PTA on radiographs, 8,10,18,21,25,26,28 this is a potential source of bias. We believe it would be reasonable to obtain a CT should the concern of accurately measuring the PTA on a lateral radiograph arise.…”

“…Several studies have demonstrated high interobserver and intraobserver reliability of the PTA measurement method described by Palm et al, which relies on appreciating the cortical lines of the femoral head and neck. 8,10,18,21,25,26,28 If adequate lateral radiographs to measure the posterior tilt are difficult to obtain, augmenting the workup with a CT scan and assessing axial cuts has been shown to be an effective alternative. 21 This was defined as the "retroversion angle" by Shin et al, 21 which provides a similar assessment to PTA seen on lateral radiographs, demonstrating a 0.961 interobserver correlation coefficient.…”

“…6 It is important to note that there can be fractures classified as "incomplete" or "nondisplaced" Garden I or II with a PTA greater than 20-degrees because the classification is based on an AP radiograph while the angle measurement is based on a lateral radiograph. 2,[9][10][11] The purpose of this systematic review and meta-analysis was to assess the association between preoperative PTA and risk of treatment failure after internal fixation of nondisplaced femoral neck fractures.…”

Validation of direct CT measurement of malrotation in femoral neck fractures: A bone model study

“…A preoperative and precise assessment of the posterior tilt is optimal for the surgeon to determine the need for optimal reduction. Taking into account that this subtype of Garden type I and II with posterior tilt greater than 20° behaves like an unstable fracture, causing avascular necrosis due to vascular kinking and tearing, an exact preoperative assessment, especially in elderly patients, may elicit primary arthroplasty [ 24 , 25 ]. However, because usually applied measurement techniques do not fit for areas proximal to the intertrochanteric line, an objective and valid technique to measure the amount of malrotation in this area seems necessary for clinical translation.…”

“…In general, any malrotation of the femur comes with impairment in patient outcomes, regardless of location, when considering osteosynthesis. While issues with malrotation in the femoral shaft are described [11,12,17,[21][22][23][24][25], Male ´ř et al report a doubling of cutout rate when malrotation exceeds 15˚in the intertrochanteric region, showing the need for anatomic reduction [26]. Fractures of the basicervical femoral neck are treated with osteosynthesis.…”