The influence of the CT scan in the evaluation and treatment of nondisplaced femoral neck fractures in the elderly

Abstract

Background: The management of nondisplaced femoral neck fractures (FNFs) has evolved, with emphasis in radiographic features such as posterior displacement. However, the role of advanced imaging in this scenario is still not well defined. Therefore, our objective is to assess the impact of a computed tomography scan (CT) on interobserver agreement (IA) of fracture classification, posterior tilt measurement, and treatment decisions in nondisplaced FNF in elderly patients. Methods: Eleven patients with a nondisplaced (Garden 1-2) FNF were assessed by six hip surgeons. On a first stage, fracture classification, posterior tilt, and treatment plan (fixation/arthroplasty) were determined only with clinical information and X-rays. On a second stage, a CT was added. The kappa coefficient (k) and intraclass correlation coefficient (ICC) were used to determine IA. Results: IA for Garden classification was only slight in X-rays and with the addition of a CT, with a k ¼ 0.13 (0-0.28) and 0.18 (0.03-0.33), respectively. Conversely, posterior tilt measurement agreement was excellent in both schemes, with an ICC ¼ 0.92 (0.83-0.98) and 0.92 (0.82-0.98). The IA for the proposed treatment was slight with X-rays (k ¼ 0.44; 0.29-0.6), but moderate with the addition of a CT scan (k ¼ 0.67; 0.52-0.82). Changes in surgical decision where made in 14 of 66 evaluations with an OR ¼ 1.4 (0.62-3.2) for choosing an arthroplasty if a CT was used. Conclusion: IA for fracture classification and posterior tilt evaluation in nondisplaced FNF was not altered by the usage of a CT. There is improvement in treatment agreement when a CT scan is added to conventional imaging, with changes in treatment in 21% of cases.

An overview on the treatment strategies of non-displaced femoral neck fracture in the elderly

“…Currently, the optimal treatment for NDFNFs is still controversial because few RCTs with a high level of evidence were conducted. The major considerations include postoperative function, complications, reoperation rate, and total cost [ 26 , 34 , 45 – 47 ]. You et al [ 48 ] indicated that internal fixation was associated with mild pain and better patient satisfaction but was associated with a high re-operation rate (20%).…”

Prediction Models for Prognosis of Femoral Neck–Fracture Patients 6 Months after Total Hip Arthroplasty

“…It improves accuracy in fracture classification, which helps in selecting the best treatment for patients with fractures. 16 CT can scan the transverse and longitudinal sections, which is more conducive to discovering fractures and helps in diagnosing occult femoral neck fracture or microfractures to avoid missed diagnosis or the wrong choice of surgical procedure. 31 , 32 A better understanding of the status of femoral neck fractures is essential for preoperative evaluation and is associated with a better surgical and clinical outcome.…”

“… 15 Computed tomography (CT) is a diagnosis tool for femoral neck fractures and provides preoperative evaluation for helping to choose the best treatment and provide better surgical and clinical outcomes. 16 , 17 Quantitative analysis of bone-texture features from CT scans has been actively applied to evaluate the status, quality, or microarchitecture of bones. 18 Park et al demonstrated the value of CT in prediction of avascular necrosis after femoral neck fracture.…”

Prediction of femoral head necrosis after Garden type I fracture with CT three-dimensional reconstruction

“…However, the measurement of posterior tilt by X-ray lateral radiographs is limited by non-standard position, anatomical variation, bone density and image quality. Zamora and colleagues [14] proposed that CT axial oblique plane can make up for the limitations of X-ray measurement, but this measurement method only uses one axial oblique 2D tomographic CT image, which is still affected by selection bias and hip position. In this study, the measurement of the posterior tilt is an improvement of Wu and colleagues [15] measurement method, because there is still a certain error in the establishment of the center of the femoral head at four points.…”