Assessing osteonecrosis of the femoral head after internal fixation of femoral neck fractures in young patients with fixation implants in situ: the value of MARS MRI in relation to conventional radiography and patient-reported outcomes.

BACKGROUND AND PURPOSE: Little is known on the use of metal artifact reduction sequence (MARS) MRI to diagnose osteonecrosis of the femoral head (ONFH) after fixation of femoral neck fractures (FNF) with conventional metal implants present. We compared MARS MRI with radiography in diagnosing ONFH. Secondarily, we determined whether signs of ONFH on MARS MRI correlate with patient-reported outcomes (PROs) via Oxford Hip Score (OHS) and pain (VAS). PATIENTS AND METHODS: 30 adults under 60 years treated with internal fixation after FNF were prospectively included (2015-2018) at 2 hospitals. They were followed up with radiography and PROs at 4, 12, and 24 months and MARS MRI at 4 and 12 months. OHS < 34 or VAS pain > 20 was considered significant. RESULTS: At 12 months, 14 patients had a pathological MRI. 3 of 14 had ONFH on radiographs at 12 months, increasing to 5 at 24 months, and 4 had unfavorable PROs. 2 of 5 patients with ONFH signs on both MRI and radiography had unfavorable PROs. 1 of 10 patients with normal MRI and radiography had unfavorable 2-year PROs. 4 patients had inconsistent MRI results, of which 1 developed ONFH. 1 patient dropped out. CONCLUSION: Information from a pathological MRI was not useful, as a majority remained free from symptoms and ONFH signs on radiographs. Furthermore, PROs did not correlate with imaging results. MARS MRI findings must be better understood before being taken into clinical practice. However, a normal MARS MRI seems to be a good prognostic finding.

The different strategies in treating displaced femoral neck fractures: mid-term surgical outcome in a register-based cohort of 1,283 patients aged 60-69 years.

BACKGROUND AND PURPOSE: In patients around retirement age controversy exists as to whether to treat displaced femoral neck fracture (dFNF) with internal fixation (IF) or arthroplasty. An arthroplasty in this age group may need revision due to a long expected remaining lifetime. IF carries a higher risk of early failure but a maintained native hip if healing occurs. We aimed to determine the cumulative 5-year rate of conversion to arthroplasty after IF and implant revision after primary total hip arthroplasty (THA), respectively. PATIENTS AND METHODS: In this longitudinal cohort study, patients aged 60-69 years registered with a dFNF in the Swedish Fracture Register (SFR) 2012-2018 were cross-referenced with available data from the Swedish Arthroplasty Register (SAR) until December 31, 2019. Conversion to arthroplasty or revision were analyzed utilizing competing risk, with death as competing event. RESULTS: At 5 years, the cumulative rate of conversion to arthroplasty after IF was 31% (95% confidence interval [CI] 26-37). For primary THA, the 5-year rate of revision was 4.0% (CI 2.8-5.8). The 5-year mortality did not differ, being 20% (CI 16-27) and 23% (CI 20-28) after IF and THA, respectively. Regression analyses did not identify any risk factors for conversion arthroplasty based on the variables in the register. CONCLUSION: A follow-up of 5 years catches most reoperations after IF, resulting in a 31% conversion rate. The 4% revision rate at 5 years after primary THA should be seen as an intermediate result, as late complications may occur.

Frailty and osteoporosis in patients with hip fractures under the age of 60-a prospective cohort of 218 individuals.

Research on younger patients with hip fractures is limited. This study adds knowledge on patient and injury characteristics, and DXA was investigated at the time of the fracture. Risk factors for osteoporosis and fractures were numerous among young patients, and osteoporosis was markedly more prevalent than in the general population. INTRODUCTION: Knowledge on younger patients with hip fractures is limited. Common preconceptions are that they suffer fractures due to high-energy trauma, alcohol or substance use disorder but not associated to osteoporosis. We aimed to descriptively analyze the characteristics of young and middle-aged patients with hip fractures and examine bone mineral density (BMD) by dual-energy x-ray absorptiometry (DXA) at the time of the fracture. METHODS: A prospective multicenter cohort study on adult patients with hip fractures below age 60 collected detailed information on patient characteristics regarding demographics, trauma mechanism, previous fractures, comorbidity and medication, and lifestyle factors. DXA results were compared to population-based reference data. RESULTS: The cohort contains 91 women and 127 men, median age 53 (IQR 47-57). Most fractures, 83%, occurred in patients aged 45-59. Two-thirds of all fractures resulted from low-energy trauma. Half of the patients had prior fractures after age 20. Thirty-four percent were healthy, 31% had one previous disease, and 35% had multiple comorbidities. Use of medication associated with increased fracture risk was 32%. Smoking was prevalent in 42%, harmful alcohol use reported by 29%, and signs of drug-related problems by 8%. Osteoporosis according to WHO criteria was found in 31%, osteopenia in 57%, and normal BMD in 12%. CONCLUSION: In patients with hip fractures below age 60, risk factors for osteoporosis and fractures were numerous. Moreover, the prevalence of osteoporosis was markedly higher than in the general population. We suggest that young and middle-aged patients with hip fractures undergo a thorough health investigation including DXA, regardless of trauma mechanism.

Lingering challenges in everyday life for adults under age 60 with hip fractures - a qualitative study of the lived experience during the first three years.

PURPOSE: We aimed to illuminate the lived experiences and the path of recovery for adults sustaining a hip fracture before the age of 60. METHODS: Participants were purposively sampled from a prospective multicenter cohort study in Sweden and Denmark, and narrative interviews were conducted with 19 individuals 0.7-3.5 years after the fracture. We used a phenomenological hermeneutic method to describe the participants' expressed essential meaning. RESULTS: The experience of sustaining a hip fracture was expressed as a painful and protracted process of regaining self-confidence, function, and independence. It also implied a sense of growing old from one day to the next. Participants were afraid of new falls and fractures, resulting in an increased wariness. When expressing fears and persisting symptoms, participants described being neglected and marginalized by the healthcare system, which was perceived as non-receptive and routinely driven by a notion that hip fractures affect only the elderly. Rehabilitation targeted towards needs different from those of elderly individuals was requested. CONCLUSION: The lived experience of sustaining a hip fracture in individuals under 60 includes substantial challenges in everyday life, even up to 3.5 years after the injury. Rehabilitation pathways tailored to the needs of younger patients are requested.