The classification algorithms to support the management of the patient with femur fracture.

Effectiveness in health care is a specific characteristic of each intervention and outcome evaluated. Especially with regard to surgical interventions, organization, structure and processes play a key role in determining this parameter. In addition, health care services by definition operate in a context of limited resources, so rationalization of service organization becomes the primary goal for health care management. This aspect becomes even more relevant for those surgical services for which there are high volumes. Therefore, in order to support and optimize the management of patients undergoing surgical procedures, the data analysis could play a significant role. To this end, in this study used different classification algorithms for characterizing the process of patients undergoing surgery for a femoral neck fracture. The models showed significant accuracy with values of 81%, and parameters such as Anaemia and Gender proved to be determined risk factors for the patient's length of stay. The predictive power of the implemented model is assessed and discussed in view of its capability to support the management and optimisation of the hospitalisation process for femoral neck fracture, and is compared with different model in order to identify the most promising algorithms. In the end, the support of artificial intelligence algorithms laying the basis for building more accurate decision-support tools for healthcare practitioners.

Evaluation of the Intraobserver and Interobserver Agreements of the New AO/OTA Classification for Fractures of the Trochanteric Region and the Femoral Neck / Avaliação das concordâncias intra e interobservadores da nova classificação AO/OTA para fraturas da região trocantérica e do colo do fêmur

Abstract Objective In the present study, we investigated the intra and interobserver agreement of the new Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification for fractures of the proximal extremity of the femur. Methods One hundred hip radiographs were selected from patients who suffered fractures of the trochanteric region or femoral neck. Four orthopedists, fellowship trained hip surgeons, and four orthopedic residents evaluated and classified fractures according to the new AO/OTA system on two separate occasions. The kappa (k) coefficient was used to evaluate intra and interobserver agreement in the different steps of the classification, namely: type, group, subgroup, and qualifier. Results Hip surgery experts obtained almost perfect intraobserver agreement of type, substantial for group and, only moderate, for subgroup and qualifiers. The residents had lower performance, with substantial agreement for type, moderate for group, and reasonable for subgroup and qualifier. In the specialists' interobserver evaluation, there was also a gradual decrease in the agreement between type (almost perfect) and group (moderate), which was even lower for subgroup and qualifiers. Residents had a substantial interobserver agreement for type, moderate for group, and reasonable in the other branches. Conclusion The new AO/OTA classification for fractures of the trochanteric region and femoral neck showed intra and interobserver agreements considered appropriate for type and group, with a drop in the subsequent branches, that is, for subgroup and qualifier. Still, in relation to the old AO/OTA classification, there was an improvement in the agreements for subgroup.

Resumo Objetivo Neste estudo, investigamos a concordância intra e interobservador da nova classificação Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) para fraturas da extremidade proximal do fêmur. Métodos Foram selecionadas 100 radiografias do quadril de pacientes que sofreram fraturas da região trocantérica ou do colo do fêmur. Quatro ortopedistas cirurgiões de quadril e quatro residentes de ortopedia e traumatologia avaliaram e classificaram as fraturas segundo o novo sistema AO/OTA em duas ocasiões distintas. O coeficiente de kappa (k) foi utilizado para avaliar a concordância intra e interobservadores nos diferentes passos da classificação, a saber: tipo, grupo, subgrupo e qualificador. Resultados Especialistas em cirurgia do quadril obtiveram concordância intraobservador quase perfeita de tipo, substancial para grupo e, apenas moderada para subgrupo e qualificadores. Os residentes tiveram desempenho inferior, com concordância substancial para o tipo, moderada para o grupo, e razoável para o subgrupo e qualificador. Na avaliação interobservadores dos especialistas, também se observou queda gradual da concordância entre tipo (quase perfeita) e grupo (moderada), que se mostrou ainda menor parasubgrupo e qualificadores.Residentestiveramumaconcordânciainterobservadoressubstancialparatipo, moderada para grupo e razoável nas demais ramificações. Conclusão A Nova Classificação AO/OTA para fraturas da região trocantérica e do colo do fêmur mostrou concordâncias intra e interobservadores consideradas adequadas para tipo e grupo com queda nas ramificações subsequentes ou seja para subgrupo e qualificador. Ainda assim em relação à classificação AO/OTA antiga houve melhora nas concordâncias para subgrupo.

Case report of a delayed iatrogenic Pipkin type III femoral head fracture-dislocation.

RATIONALE: Pipkin III femoral head fracture dislocation (FHFD) is rarely observed in clinical practice, and its outcome is alarming. A considerable proportion of Pipkin III fractures result from repeated or forceful closed reduction of an irreducible FHFD. Pipkin type III fractures pose a therapeutic challenge. Most patients underwent total hip arthroplasty. PATIENT CONCERNS: A 34-year-old man experienced high-energy trauma to the left hip from a terrible traffic accident. Radiography and computed tomography (CT) at the local hospital revealed a left posterior FHFD. Emergency close reduction of the hip was performed.48 hours later, the patient was transferred to our institution. New radiography and CT examinations demonstrated an iatrogenic femoral neck fracture (FNF) associated with FHFD. In addition, a right talar fracture was observed. DIAGNOSIS: Pipkin III fracture combined with contralateral talar fracture. INTERVENTIONS: Considering his Pipkin fracture classification (Pipkin Type-III) and the time to surgery after his injury (>48 hours), the patient underwent left total hip arthroplasty uneventfully, followed by below-ankle plaster cast immobilization for his right ankle. OUTCOMES: At the 6-month follow-up, the patient was able to walk pain-free, and plain radiographs were satisfactory, with no evidence of heterotopic ossification or osteonecrosis of the talus. LESSONS: Before emergency closed reduction, early recognition of the unique characteristics of an irreducible FHFD is essential to avoid iatrogenic femoral neck fracture.

Management of proximal femur fractures in the elderly: current concepts and treatment options.

As one of the leading causes of elderly patients' hospitalisation, proximal femur fractures (PFFs) will present an increasing socioeconomic problem in the near future. This is a result of the demographic change that is expressed by the increasing proportion of elderly people in society. Peri-operative management must be handled attentively to avoid complications and decrease mortality rates. To deal with the exceptional needs of the elderly, the development of orthogeriatric centres to support orthogeriatric co-management is mandatory. Adequate pain medication, balanced fluid management, delirium prevention and the operative treatment choice based on comorbidities, individual demands and biological rather than chronological age, all deserve particular attention to improve patients' outcomes. The operative management of intertrochanteric and subtrochanteric fractures favours intramedullary nailing. For femoral neck fractures, the Garden classification is used to differentiate between non-displaced and displaced fractures. Osteosynthesis is suitable for biologically young patients with non-dislocated fractures, whereas total hip arthroplasty and hemiarthroplasty are the main options for biologically old patients and displaced fractures. In bedridden patients, osteosynthesis might be an option to establish transferability from bed to chair and the restroom. Postoperatively, the patients benefit from early mobilisation and early geriatric care. During the COVID-19 pandemic, prolonged time until surgery and thus an increased rate of complications took a toll on frail patients with PFFs. This review aims to offer surgical guidelines for the treatment of PFFs in the elderly with a focus on pitfalls and challenges particularly relevant to frail patients.

Outcomes of Femoral Neck Fractures Treated with Cannulated Internal Fixation in Elderly Patients: A Long-Term Follow-Up Study.

OBJECTIVES: To evaluate the long-term efficacy of cannulated internal fixation in patients who sustain femoral neck fracture (FNF) and risk factors influencing the outcomes. METHODS: This retrospective study analyzed data from 73 elderly patients aged ≥60 years old, hospitalized for FNF and treated with cannulated internal fixation between August 2008 and July 2016. The inclusion criteria were: (i) patients aged ≥60 years; (ii) patients with recent femoral neck fracture, with times of injury ranging from 12-72 h; and (iii) patients who underwent Garden II-IV closed reduction and internal fixation. Patients were classified based on the Garden fracture type and Pauwels angle. Clinical data and radiographs before and after the surgery were collected. Subsequently, surgery was performed with the patient in supine position, under general or lumbar epidural anesthesia. Closed reduction was performed until satisfactory fracture reduction quality was achieved. The weight of all included patients were <75 kg, and thus, minimal internal fixation was performed. The ischemic necrosis of the femoral head was diagnosed by considering the symptoms, signs, and radiological findings. Harris hip scores were used to evaluate postoperative recovery of hip function. Furthermore, relationships between Garden fracture type and necrosis rate of the femoral head, Pauwels angle and necrosis rate of the femoral head, Garden fracture type and Harris hip score, and age and Harris hip score were analyzed. RESULTS: The mean duration of surgery was 1 ± 0.17 h and blood loss for all the patients was approximately 15 mL. The included patients were followed up for 13-128 months, with an average follow-up of 61 months. Among the included 73 patients, 65 (89.0%) exhibited satisfactory union, seven (9.6%) had femoral head necrosis, and one (1.4%) had nonunion. For seven patients with femoral head necrosis, there were two, two, and three patients classified as Garden IV, Garden III, and Garden II, respectively, and two and five patients classified as Pauwels II and Pauwels III, respectively. Among the seven cases, four underwent hip replacement. Garden fracture type was not significantly associated with femoral head necrosis (χ2 = 0.44, P > 0.05) or Harris score (χ2 = 1.43, P > 0.05). Patients with Pauwels I (0%) and II (4.3%) fractures exhibited a significantly lower necrosis rate than those with Pauwels III fractures (41.7%) (P < 0.05). CONCLUSIONS: Cannulated internal fixation was more suitable for older Chinese patients with Pauwels I/II fractures than those with Pauwels III fractures.

Reliability of International Classification of Disease-9 Versus International Classification of Disease-10 Coding for Proximal Femur Fractures at a Level 1 Trauma Center.

INTRODUCTION: The Centers for Medicare & Medicaid services proposed that transitioning from the 9th to the 10th revision of the International Classification of Disease (ICD) would provide better data for research. This study sought to determine the reliability of ICD-10 compared with ICD-9 for proximal femur fractures. METHODS: Available imaging studies from 196 consecutively treated proximal femur fractures were retrospectively reviewed and assigned ICD codes by three physicians. Intercoder reliability (ICR) was calculated. Collectively, the physicians agreed on what should be the correct codes for each fracture, and this was compared with coding found in the medical and billing records. RESULTS: No significant difference was observed in ICR for both ICD-9 and ICD-10 exact coding, which were both unreliable. Less specific coding improved ICR. ICD-9 general coding was better than ICD-10. Electronic medical record coding was unreliable. Billing codes were also unreliable, yet ICD-10 was better than ICD-9. DISCUSSION: ICD-9 and ICD-10 lack reliability in coding proximal femur fractures. ICD-10 results in data that are no more reliable than those found with ICD-9. LEVEL OF EVIDENCE: Level I diagnostic.

Comparative analysis for five fixations of Pauwels-I by the biomechanical finite-element method.

Background: Little is known about how biomechanics govern the five fixtures such as DHS, MLS, DHS + LS, LP, and HA are accepted as common therapeutic techniques. Aims and objectives: A series of numerical models for a femoral neck fracture of Pauwels-I will be constructed by innovative approach of finite element in order to determine the most optimized option in comparison with biomechanical performance. Method: Twenty sets of computer tomography scanned femora were imported onto Mimics to extract 3 D models; these specimens were transferred to Geomagic-Studio for a simulative osteotomy and kyrtograph; then, they underwent UG to fit simulative solid models; 5 sorts of fixture were then expressed by Pro-Engineer virtually. After processing with HyperMesh, all compartments (fracture model + internal implant) were assembled onto 5 systems: "Dynamic Hip Screw (DHS), Multiple Lag screw (MLS), DHS + LS, femoral Locking Plate (LP) and HemiArthroplasty (HA)." Eventually, numerical models of the finite-elemental analysis were exported to AnSys to determine the solution. Result: Four models of fixation and a simulation of HA for Pauwels-I were established, validated, and analyzed with the following findings: In term of displacement, these 5 fixtures ranged between 0.3801 and 0.7536 mm have no significant difference; in term of stress, the averages of peaks for integral assemblage are b(MLS) = 43.5766 ≈< d(LP) = 43.6657 ≈< e(Ha) = 43.6657 < c(DHS + LS) = 66.5494 < a(DHS) = 105.617 in MPa indicate that MLS, LP and HA are not significantly different, but less than DHS + LS or DHS in each. Conclusion: A fixture of MLS or LP with optional HA should be recommended to clinically optimize a Pauwels-I facture.

Can we predict failure of percutaneous fixation of femoral neck fractures?

PURPOSE: This study evaluated a series of geriatric femoral neck fracture treated with closed reduction percutaneous pinning (CRPP) at a single level-1 trauma center to determine if there are any simple, reliable, radiographic characteristics that can be used to predict increased risk of post-operative failure in nondisplaced and valgus impacted fracture patterns. METHODS: We conducted a retrospective cohort study of all patients with femoral neck fractures (AO/OTA 31B) who underwent CRPP over a 12-year period at a single Level 1 trauma center. Failure was defined as radiographic failure within the first year after the index operation requiring revision surgery. Common patterns identified on initial review were the presence of a visible medial transcervical line (MTL) felt to indicate a tension-sided failure, a straight inferior calcar (SIC) indicating severe valgus impaction, and quality of intra-operative screw positioning. X-rays of patients were then reviewed for these characteristics in a blinded manner by three different trauma-fellowship trained orthopedic surgeons. Inter-rater reliability was calculated using Fleiss' Kappa Coefficient. Comparisons of failure rates between groups were made using a Fisher's Exact test. RESULTS: 139 patients who underwent CRPP for a femoral neck fracture and follow-up for at least 90 days were identified and reviewed. There were a total of 19 failures (13.6%) within one year. The patients with a varus fracture had a failure rate of 9/24 (37.5%). Of the valgus/nondisplaced fractures, MTL was identified in 42/115 (36%) patients. Inter-rater agreement was high for the presence of an MTL (84%, Kappa 0.69). Patients with an MTL had a fourfold increase in risk of failure (7/42=17% with an MTL vs. 3/73=4% without, p  0.03). The presence of a SIC and quality of screw placement were not predictive of failure. CONCLUSION: Varus femoral neck fractures fixed with CRPP have a high rate of failure (37.5%). Nondisplaced or valgus impacted fractures with the presence of a visible medial transcervical line on pre-operative radiographic imaging resulted in a fourfold increase in the risk of failure after CRPP. Identification of the MTL will help treating surgeons better council patients when making pre-operative decisions between arthroplasty and CRPP.

Predictors of early failure of the cannulated screw system in patients, 65 years and older, with non-displaced femoral neck fractures.

BACKGROUND: Hip fractures represent the most common injury and the main cause of morbidity and mortality among patients 65 years and older. About 20% of all femoral neck fractures (FNFs) are non-displaced or valgus impacted, for which internal fixation with the cannulated screws system (CSS) is indicated. AIMS: The aim of this study was to identify predictors of early failure of CSS. METHODS: Patients with non-displaced FNFs (Garden type I and II) treated operatively using the CSS were enrolled. Their characteristics, Pauwels angle, and posterior tilt were assessed and related with outcomes. The primary outcome was fixation failure within 6 months. RESULTS: 259 patients were included with a mean age of 81.44 years. Most patients were female with ASA 3. The majority of fractures were classified as Garden I and Pauwels I. On average, Pauwels angle was 27°, while posterior tilt was 12°. A linear correlation between Pauwels angle and posterior tilt was found; the failure rate was 9.7%. Using the adjusted Cox competing risk regression analysis, posterior tilt was found to be independently associated with failure rate (sub-distribution hazard ratio or SHR 1.14 [95% CI 1.05-1.24], p = 0.0020). A posterior tilt greater than 18° resulted predictive of failure. The 1-year mortality rate was 12%. CONCLUSIONS: Non-displaced Garden type II fractures, Pauwels type II or III fractures, and a posterior tilt greater than 18° represent radiographic predictors of CSS early failure in the elderly. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

Posterior and anterior tilt increases the risk of failure after internal fixation of Garden I and II femoral neck fracture.

Background and purpose - Preoperative posterior tilt of the femoral head as seen on lateral radiographs has been reported to affect the risk of fixation failure in cases of minimally displaced femoral neck fractures (Garden I-II). We investigated radiological risk factors of treatment failure.Patients and methods - We included 417 patients (68% women, median age: 78 years (50-108) with a minimally displaced femoral neck fracture (Garden I-II) treated with internal fixation in a retrospective cohort study. The patients were followed for 3.4 years (2-14). Data on age, sex, housing, cognitive impairment, implant angulation, pre- and postoperative tilt, hip complications, and reoperations were recorded. The risk of fixation failure was assessed using Cox proportional hazards regression analysis.Results - The overall reoperation rate was 17%, and the rate of treatment failure (fixation failure, nonunion, avascular necrosis, or posttraumatic osteoarthritis) was 13%. Cox proportional hazard analysis revealed an increased risk of treatment failure with a preoperative posterior tilt of at least 20° and a preoperative anterior tilt greater than 10°. A failure occurred in 13 of the 65 patients with a posterior tilt of at least 20° and in 5 of the 9 patients with an anterior tilt greater than 10°.Interpretation - A preoperative posterior tilt of 20° and an anterior tilt greater than 10° in cases of Garden I and II femoral neck fractures increase the risk of fixation failure necessitating additional surgery. In this group of patients, there is a need for future interventional studies regarding the feasibility of primary hip arthroplasty.

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

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 ( κ) 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 κ = 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 = 0.92 (0.83-0.98) and 0.92 (0.82-0.98). The IA for the proposed treatment was slight with X-rays ( κ = 0.44; 0.29-0.6), but moderate with the addition of a CT scan ( κ = 0.67; 0.52-0.82). Changes in surgical decision where made in 14 of 66 evaluations with an OR = 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.

Surgical treatment with cannulated screws for pediatric femoral neck fractures: A case series.

INTRODUCTION: Femoral neck fractures are uncommon injuries in children, but the high incidence of long-term complications makes it important clinical entity. Early surgical treatment to achieve optimal results and to avoid a high rate of complications is widely advised. The purpose of this study was to retrospectively analyze the outcome of 8 children who sustained a femoral neck fracture. PATIENTS AND METHODS: The patients (6 boys and 2 girls with an average age of 9.2 years) were treated within 24 h following admission to hospital by closed reduction and internal fixation. The type of fracture was distinguished according to Delbet's classification system. The outcome was analyzed using Ratliff's criteria, and a detailed record of complications was maintained. RESULTS: According Delbet's classification system, there were 3 type I, 2 type II, 2 type III, and 1 type IV fractures. The average follow-up was 39.2 months (range 8-95). A satisfactory outcome was obtained in 6 (75%) children. Avascular necrosis was the most notable complication, which was reported in the 2 fair outcomes (25%). CONCLUSIONS: Early and aggressive surgical treatment aimed at anatomical reduction result in a satisfactory outcome in pediatric femur neck fractures. Development of avascular necrosis is the main complication.

[A mini-incision on the anterior hip for pediatric femur neck fractures of type Delbet â ¡].

Objective: To investigate the early clinical outcomes of hip anterior short incision and open reduction and internal fixation for the treatment of children with Delbet Ⅱ femoral neck fracture. Methods: A retrospective analysis of 12 children with DelbetⅡ femoral neck fractures was performed with the anterior short incision approach at Department of Pediatric Orthopaedic, Children's Hospital, Nanjing Medical University from January 2014 to August 2016. There were 7 males and 5 females including 8 cases at left side and 4 cases at right side,aged (11.5±0.8) years (range: 8-14 years).Patients underwent surgery in (12.0±0.9) hours (range: 6-20 hours) after the injury. Displaced fractures were treated by open reduction if closed reduction failed.The surgical incision was performed with the anterior inferior iliac spine centered on, extending along the groin crease, and the length was 3 to 4 cm. The interval between the sartorius and the tensor fascia latae was applied, and the direct and indirect head of rectus femoris were resected to visualize the hip joint capsule. T-shaped incision was made in the capsule. After the reduction was obtained, two or three compression canulated screws were used to fix the fracture site. The healing time, complications and corresponding record outcome by X-ray and clinical examination were recorded. At the latest follow-up,the results were analyzed using the Ratliff criteria and clinical outcomes were assessed by pain, restrictive hip movement, normal activity or the avoidance of games, and the femoral neck in the radiograph. Results: Twelve patients had been followed-up for (30.0±4.1)months(range: 24-36 months). X-ray showed the fractures' healing time was (8.0±0.4) weeks(range: 7-9 weeks). Ten of the 12 fractures healed after one operation and were associated with no evidence of osteonecrosis of the femoral head. One case occurred premature physeal closure. There were no cases with fracture relocation, coaxvara, delayed union and nonunion or any significant postoperative complications. There was no infection, flexible internal fixation or ruptures. According to Ratliff grade, 9 cases of 12 patients were fine and 3 cases was acceptable. Conclusions: Satisfactory short-term effects can be achieved by a mini-incision on the anterior hip for Delbet Ⅱ pediatric femur neck fractures. The anterior incision has the advantage of less trauma, smaller incision scar, better fracture reduction and fixation, and less wound complications.

Fragility fractures of the proximal femur: review and update for radiologists.

Proximal femoral fragility fractures are common and result in significant morbidity and mortality along with a considerable socioeconomic burden. The goals of this article are to review relevant proximal femoral anatomy together with imaging, classification, and management of proximal femoral fragility fractures, and their most common complications. Imaging plays an integral role in classification, management and follow-up of proximal femoral fragility fractures. Classification of proximal femoral fragility fractures is primarily based on anteroposterior hip radiographs. Pertinent imaging features for each category of proximal femoral fractures that would guide management are: differentiating nondisplaced from displaced femoral neck fractures, distinguishing stable from unstable intertrochanteric fractures, and determining the morphology and comminution of subtrochanteric fractures. Treatment of proximal femoral fragility fractures is primarily surgical with either arthroplasty or internal fixation. Intramedullary nailing is used in the treatment of some types of proximal femoral fragility fractures and may be associated with unique complications that become evident on postoperative follow-up radiographs.

Internal Rotation Traction Radiograph Improves Proximal Femoral Fracture Classification Accuracy and Agreement.

OBJECTIVE: The objective of this study is to assess the clinical utility of internal rotation traction radiography in the classification of proximal femoral fractures. MATERIALS AND METHODS: The study cohort included 78 consecutive patients who were surgically treated for a proximal femoral fracture and for whom preoperative physician-assisted internal rotation traction radiographs of the fractured hip were obtained in addition to standard radiographs. Two radiologists who were blinded to clinical information independently classified each fracture without the traction view and then with the traction view. The radiologists also reported their confidence (expressed as a percentage) in their classifications. The reference standard was the consensus interpretation of intraoperative C-arm fluoroscopic images by two orthopedic surgeons and one radiologist. Classification accuracy was compared using the McNemar test. Subjective confidence and confidence-weighted accuracy were compare using paired t tests. Agreement with the reference standard and interreader agreement were calculated using the kappa statistic and were compared using the z-test after bootstrapping was performed to obtain the standard error. RESULTS: With the traction view, the pooled accuracy increased from 44.9% to 72.4%, subjective confidence increased from 87% to 94%, and confidence-weighted accuracy increased from 51.7% to 74.3% (p < 0.001). With the traction view, the kappa statistic for agreement with the reference standard increased from 0.530 to 0.791 and from 0.381 to 0.625 for the two readers, and interreader agreement increased from 0.480 to 0.678 (p < 0.001). CONCLUSION: The addition of an internal rotation traction radiographic view significantly improves radiologist accuracy and confidence as well as interreader agreement in the classification of proximal femoral fractures, all of which would be expected to best guide appropriate surgical management.

Management of Pediatric Femoral Neck Fracture.

In the pediatric population, femoral neck fracture is a relatively uncommon injury with a high complication rate, despite appropriate diagnosis and management. The anatomy and blood supply of the proximal femur in the skeletally immature patient differs from that in the adult patient. Generally, these fractures result from high-energy trauma and are categorized using the Delbet classification system. This system both guides management and aids the clinician in determining the risk of osteonecrosis after these fractures. Other complications include physeal arrest, coxa vara, and nonunion. Multiple fracture fixation methods have been used, with the overall goal being anatomic reduction with stable fixation. Insufficiency fractures of the femoral neck, although rare, must also be considered in the differential diagnosis for the pediatric patient presenting with atraumatic hip pain.

Stability of L-shaped and inverted triangle fixation assemblies in treating Pauwels type II femoral neck fracture: a comparative mechanical study.

PURPOSE: The aim of our study is to compare the mechanical resistance of two screw configurations in fixating type II Pauwels femoral neck fractures. METHODS: Fifteen synthetic models of femur bones in young adults were divided into three equal groups: intact (G1), models with fixation of a 5.0-mm failure zone created in the posterior cortex of the femoral neck using an L-shaped screw arrangement (G2, n = 5), and models with an identical failure zone fixated using an inverted triangle assembly (G3, n = 5). Model strength (axial loading) and rotational deviation of the fragments were load-tested until a 5.0-mm displacement was reached (step 1) and then until failure, here considered as 10.0 mm displacement in G2 and G3 or femoral neck fracture in G1 (step 2). RESULTS: In step 1, the mean resistance in G1 was 1593 N (standard deviation [SD] of 62 N); this value in G2 was 1261 N (SD 49 N) and in G3 was 1074 N (SD 153 N). During step 2, the value for G1 was 2247 N (SD 84 N), for G2 was 1895 N (SD 69 N), and for G3 was 1523 N (SD 280 N). G3 (the inverted triangle assembly) showed a significantly lower maximum load than the group using the L-shaped assembly (G2) and the control group (G1), which was significant using Kruskal-Wallis analysis of variance (p = 0.002). CONCLUSION: Under test conditions in synthetic bone, fixation using a L-shaped screw assembly provides greater mechanical resistance than an inverted triangle assembly.

Risk factors of fixation failure in basicervical femoral neck fracture: Which device is optimal for fixation?

BACKGROUND: Basicervical femur neck fracture (FNF) is a rare type of fracture, and is associated with increased risk of fixation failure due to its inherent instability. The purpose of this study was (1) to investigate the incidence of fixation failure and (2) to determine risk factors for fixation failure in basicervical FNF after internal fixation. METHODS: To identify basicervical FNF with a minimum of 12 months follow-up, we retrospectively reviewed records of 3217 patients who underwent hip fracture surgery from May 2003 to March 2016. Among the identified 77 patients with basicervical FNF, 69 patients were followed up for at least 12 months. We evaluated the rate of collapse of fracture site and reoperation due to fixation failure. We performed a multivariable analysis to determine risk factors associated with fracture site collapse and fixation failure. RESULTS: Among the 69 patients with basicervical FNF, 17 (24.6%) showed collapse of fracture site, and 6 (8.6%) underwent conversion to arthroplasty because of fixation failure. In the multivariable analysis, use of extramedullary plating with a sliding hip screw was an independent significant risk factor for both collapse of fracture site (odds ratio 6.84; 95% confidence interval 1.91-24.5, p = 0.003) and fixation failure (odds ratio 12.2; 95% confidence interval 1.08-137.7, p = 0.042). CONCLUSIONS: Basicervical FNF treated with extramedullary plate with a sliding hip screw is more likely to fail than that treated with intramedullary nail with a helical blade. Our results suggested that intramedullary nail with a helical blade is more recommended for basicervical FNF compared with extramedullary plate with a sliding hip screw. LEVEL OF EVIDENCE: III, Retrospective cohort study.