Inclusion and exclusion criteria
Inclusion criteria: 1. All patients with age of ≤ 65 years, who were diagnosed with femoral neck fracture based on both imaging and Physical examination. 2. The procedure was gotfried closed reduction and internal fixation with cannulated cancellous screws. 3. Patients had no hip dysplasia neither arthritis before the injury. 4. All cases had at least one year of complete follow-up data
Exclusion criteria: 1. Pathological fractures, acetabular injuries, preexisting ipsilateral hip diseases, or femoral head fracture. 2. Multiple-trauma patients 3. Traumatic Brain Injury and Glasgow score < 14. 4. Patients with severe Cognitive Impairment and mental illness.
The Institutional Ethics Committee approved the present study of our hospital. All patients were included in the study after signing the informed consent.
The General Information
A total of 67 patients who finally met the inclusion criteria and had complete follow-up data were divided into three groups according to the first Imaging results after surgery. Group A was the anatomical reduction group, Group B was the Gotfried positive buttress reduction group, and group c was Gotfried negative buttress reduction group. There were 21 patients in group A, 12 males, and 9 females; the average age was 49.7 ± 11.6 years; the average follow-up time was 22.4 ± 10.7 months; Garden classification of fractures: 7 cases of type I, 5 cases of type II, 4 cases of type III, and 5 cases of type IV; 24 cases in group B, 14 cases of male and 10 cases of the female; the average age was 48.6 ± 11.3 years; the average follow-up time was 22.1 ± 11.2; Garden classification of fractures: 8 cases of type I, 6 cases of type Ⅱ, 5 cases of type Ⅲ, and 5 cases of type IV; 22 cases of group C, 13 cases of male, and 9 cases of the female; mean age was 48.3 ± 12.4 years; mean follow-up time was 22.8 ± 11.6; Garden classification of fracture: 4 cases of type I, 7 cases of typeⅡ,5 cases of type III, and 6 cases of type IV.
Surgical Procedures
All fractures underwent gotfried closed reduction and internal fixation with cannulated cancellous screws. The patient was placed on an orthopedic traction bed after anesthesia, and the perineum was protected against the traction site. The lower limb traction was performed on the operative side: lower limb abduction and knee flexion, hip flexion on the contralateral side for convenient fluoroscopy during operation.
Gotfried closed reduction technology could be divided into three different steps as follows: 1. Gradually increased traction is applied in 2 directions: first, lateral: using a towel that was wrapped around the upper tight and second longitudinal: on the leg utilizing fracture table. 2. Reduction—while under traction in both directions, the lower limb is brought into adduction and internal rotation. Usually, about 45 degrees adduction is required. The third stage, not presented in the drawing: reconstruction—while in adduction and internal rotation, the release of longitudinal and lateral traction.
Percutaneous cannulated screw fixation: Insert a threaded guide needle in front of the femoral neck to determine the anteversion angle under fluoroscopy. Insert the guide needle at the position of the trochanter slightly above the centerline of the femur. The direction is parallel to the first positioning needle, guide-pin is drilled into place along the medial cortex of the femoral neck and head to within 5 mm of subchondral bone; Measure the length of each cannulated screw and screw in the corresponding length of the cannulated screw. The C-arm confirms the quality of fracture reduction and the screws' position to prevent the screw from penetrating the hip joint.
Postoperative Management
Intravenous prophylactic antibiotics (Cefazolin 2.0 g) were routinely administered 30 minutes preoperatively. All patients were kept in absolute bed rest for 3 days and mobilized with crutches without weight-bearing on the seventh postoperative day on the affected side. The patients received partial weight-bearing exercises with crutches after 8 weeks, and usual weight-bearing activities after 12 weeks. These patients had a positive compression ultrasound for deep-vein thrombosis and received anticoagulant therapy on the next day after the operation.
Evaluation criterion and observation index
1. Follow-up data: The follow-up duration was measured from the time of operation to the last follow-up date, and the avascular necrosis of the femoral head, malignant or nonunion of the fracture, was recorded at the last follow-up. Harris hip scoring (HHS) system was used to measure the hip function. The quality of fracture reduction is divided into anatomical reduction and non-anatomical reduction. The non-anatomical reduction is divided into Goffried positive support reduction and negative support reduction.
Statistical analysis
SPSS software was used to take the statistical analysis, Normal distribution of data tested using the Shapiro–Wilk W-test. The patient's age, follow-up time, and Harris score were normally distributed data, exhibited homogeneity of variance. Analyses were carried out using one-way ANOVA in 3 groups. If the difference was statistically significant, then the SNK-q test was used to compare the two groups. P < 0.05 considered that the difference was statistically significant significance.
Clinical Outcome
The average follow-up periods in the three groups were ( 22.4 ± 10.7)、(22.1 ± 11.2)、༈22.8 ± 11.6༉months, which showed no statistical difference(F = 0.053, P = 0.964). There was no wound infection, fracture nonunion, and implant failure in either group. No significant differences were noted preoperatively between the three groups regarding age, time of operation, gender, and average time of follow-up ((P > 0.05). There was no statistically significant difference in the femoral head necrosis rate among the three groups (P = 0.156). At the last follow-up, the Harris scores in group A and group B were significantly higher than group c, and the difference was statistically significant (P < 0.05, Table 2).
Table 1
Basic characteristics of patients
Group Case | Mean age\(\)\(\stackrel{-}{\varvec{x}}\pm \varvec{s}\) | Gender male female | Classification ( Garden) Ⅰ Ⅱ Ⅲ Ⅳ | follow-up time (month)\(\stackrel{-}{\varvec{x}}\pm \varvec{s}\) |
A | 21 | 49.7 ± 11.6 | 12 | 9 | 7 | 5 | 4 | 5 | 22.4 ± 10.7 |
B | 24 | 48.6 ± 11.3 | 14 | 10 | 8 | 6 | 5 | 5 | 22.1 ± 11.2 |
C | 22 | 48.3 ± 12.4 | 13 | 9 | 4 | 7 | 5 | 6 | 22.8 ± 11.6 |
Group A : Anatomical reduction group, |
group B : Gofffied positive buttress reduction group, |
Group C: Gotfried negative buttress reduction group |
Table 2
The incidence of femoral head necrosis and Harris score at last follow-up
Group | Case | AVN(case,%) | Harris score |
A | 21 | 4(4/21, 19.05%) | 85.6 ± 6.7 |
B | 24 | 5(5/24,20.83%) | 84.5 ± 6.2 |
C | 22 | 5(5/22,22.73%) | 74.3 ± 8.3 |
Group A : Anatomical reduction group, |
group B : Gofffied positive buttress reduction group, |
Group C: Gotfried negative buttress reduction group |
AVN: avascular necrosis |